Amending the Patient Record

Mistakes Happen

We all know that things change, and mistakes happen. Details may get overlooked. But when we are talking about documentation, you can’t simply overwrite something, use White-Out, or scribble it out with a Sharpie to amend the record. When you need to change, add, or delete something from the documentation rendered at the time of service, you must follow specific guidelines. Doing otherwise can look like you are altering or falsifying the documentation, which is considered fraudulent.

CMS says:

The medical record cannot be altered. Errors must be legibly corrected so that the reviewer can draw an inference as to their origin. These corrections or additions must be dated, preferably timed, and legibly signed or initialed.

That means that you must, at a minimum, write or record the following details in the medical record:

• The date the record is being amended
• The details of the amended information
• A statement that the entry is an addendum to the medical record
• The date of the service being amended
• The signature of the provider writing the addendum

Even though there is no requirement to explain why you are amending the patient’s record, we recommend that you do so. If something was missing from the documentation at the time of service or you are coming back to say that more information needs to be added, the first question any reviewer would ask is why you didn’t just write it down in the first place. Explaining the “why” of an amendment improves your credibility.

Here’s how to handle paper vs. electronic record amendments:

Paper Medical Records:

• Error – use a single line to strike-through so that the original content is still readable
• Omission – write in the information to be added
  • on the original note with a clear notation of what is being added
  • on a separate page with reference to the date when the note is being amended

Electronic Health Records (EHR):

• Most EHRs can amend records as a function of the software
• At a minimum, the following must occur:
  • Provider must distinctly identify any amendment, correction, or delayed entry
  • Software must provide a reliable means to clearly identify the original content, the modified content, and the date and authorship of each modification of the record

We never want a reader of patient records to stop and scratch their head regarding what they are looking at. Remember that each piece of documentation that you create to record your interaction with your patients is a legal document. The correct handling of these records is essential to ensure compliance. Be sure to revisit and update your policy on amending patient records as well as train your team with any updates.

Dr. Colleen Auchenbach graduated with a Doctor of Chiropractic from Cleveland University Kansas City in December of 1998 and enjoyed practicing for over 20 years. Her interest in Medical Compliance began when she earned the 100-hour Insurance Consultant/Peer Review certification from Logan University in 2015. She has been a certified Medical Compliance Specialist-Physician since 2016 and a Certified Professional Medical Auditor since 2022. Dr. Auchenbach joined the excellent team at KMC University as a Specialist in 2020, and as a part of this dedicated team is determined to bring you accurate, current, and reliable information. You may reach her by email at info@kmcuniversity.com or by calling (855) 832-6562.