Changing Documentation in the Medical Record

Changing Documentation in the Medical Record

by Richard Schamp, MD, Chief Executive Officer

When documenting in the medical record, providers should take care to capture their thoughts and findings as completely as possible. Best practice is to document the patient encounter at the time, or shortly afterwards. Inevitably, situations require some changes in the medical record, of which four types are recognized.  

Addendum.  Addenda add omitted information to an existing document without altering the original document. Addenda should bear the current date and reason for the additional information being added to the record. Both the original and addendum should be signed by the same provider. For the additional information to have meaning, it should be connected to the original report. Example:  Foot pain was not mentioned in original note. Addendum to original document notes “patient complained of pain in left foot, rating pain as 4 out of 10 and bruising was noted. Patient indicated contusion followed dropping a box on the foot while moving. No clinical evidence of fracture and no treatment required.”

Amendment. Amendments are used to clarify information presented in the original document without altering the original document, after the original documentation has been completed by the provider. Amendments should bear the current date of documentation. Example: Amended documentation clarifies that the reference to “foot” means patient’s left foot.

Correction. Corrections change the information in the document to amend inaccuracies after the original document has been signed or rendered complete. Example: Original document noted that the patient complained of pain in the right foot. Corrected information clarifies that pain was in the left foot.
 
Deletion. Deletions eliminate incorrect information from a closed/finalized document without substituting new information. Example: A note was placed in the wrong patient’s chart, so it is removed from the incorrect chart.

When any changes (addenda, amendments, corrections, deletions) or delayed entries in medical documentation are needed, the Medicare Program Integrity Manual (chapter 3, section 3.3.2.5) stipulates the following guidelines to comply with widely-accepted Record-keeping Principles:

Regardless of whether a documentation submission originates from a paper record or an electronic health record, documents … containing amendments, corrections or addenda must:
1. Clearly and permanently identify any amendment, correction or delayed entry as such, and
2. Clearly indicate the date and author of any amendment, correction or delayed entry, and
3. Clearly identify all original content, without deletion.

When correcting a paper medical record, these principles are generally accomplished by:
1. Use a single line strike through so the original content is still readable, and
2. The author of the alteration must sign and date the revision.

Changes to paper records must be clearly signed and dated upon entry into the record.
 
Medical recordkeeping within an electronic health record also requires the principles  specified above as fundamental and necessary. Records in electronic systems containing addenda, amendments, corrections or delayed entries must:
1. Distinctly identify any changed entry, and
2. Provide a reliable means to clearly identify the original content, the modified content, and the date and authorship of each modification of the record.”

Note that the Manual does not specify a time frame during which amendments, corrections, or delayed entries may occur. However, common sense suggests that entries made weeks or months after the encounter may be viewed as suspect.  

We strongly recommend providers and organizations protect themselves with clearly defined policies on when and how a record is considered complete.  System functionality should include limiting the end-user ability to add information or make corrections after a certain point in time (e.g., 24 hours after encounter).  Changes that need to be made after this point in time should be on a case-by-case basis.  Further policies and procedures surrounding how alterations within the record are made should be established. 

Richard Schamp, M.D.
Chief Executive Officer

 
Finally, we urge organizations to utilize the audit trail function of their EHR system to identify and trend the utilization of these functionalities. Reports should be generated in such a way to identify opportunities to provide education to individuals using it incorrectly.

If you need assistance in establishing policies and procedures or have questions about your current practices contact Capstone Performance Systems at info@cpstn.com.