Please note that this article contains information that is only relevant to American clinics.
If you regularly submit claims to Medicare, then you are aware of the regulations surrounding claims submissions. As it happens, there are quite a few rules regarding changes made to clinical documentation and medical records after the fact. In this article, we’ll be sharing the top 5 things you need to know about amended medical records.
1) An amended medical records is considered to be one of several things
There are several ways that you can make amendments to a medical record after signing and completing it. You just have to be certain to use one of the approved methods. They are as follows.
2) A late entry is an acceptable means of altering a completed medical record
A recent article from Gawenda Seminars and Consulting stated that “A late entry supplies additional information that was omitted from the original entry.” The late entry must have the current date, and under no circumstances should it be back-dated. Also, the late-entry must be completed by the therapist who originally saw the patient. This is because they’re the only one who has total recall regarding the missing information.
3) You can use an addendum to include information that wasn’t available at the original time of entry
Addendums to existing medical records must be made in a timely manner. Like late entries, it should also bear the current date, along with the reason for the addendum. It goes without saying that the addendum should be signed by the person who originally drafted the note.
4) You can make corrections to paper medical records, too
It’s okay if you want to make corrections to a paper-based clinical entry, but you must ensure that that the original note is still readable. It’s suggested that you cross out the information that you wish to remove with a single line. Additionally, you should sign and date next to the information that you removed, as well as state the reason for the correction.
If you’re making a correction to an electronic medical document, you need to keep both copies on hand, and both copies must make note of the correction.
5) Deliberately falsifying medical records is a felony offense
It should not come as a surprise that intentionally falsifying medical records is punishable by law. Whether the falsification is indicative of fraudulent activity, or the improper documentation of a patient’s medical condition, it’s equally important to follow the rules.
Examples of falsifying clinical records include: creating new records upon request, back-dating entries, post-dating entries, pre-dating entries, writing over and or adding to existing documentation (with the exception of the methods described above.)
Hint: Practice Perfect includes a feature that prevents users from editing completed and signed clinical documents. If users need to make a change to the note after the fact, it will cause the software to create an ‘annotation’.
We hope that you found this article helpful. For more information like this, head over to the Gawenda Seminars and Consulting website and learn more about the benefits of becoming a Gold Member.