Things change. Mistakes happen. Details get overlooked. But when we’re 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 as rendered at the time of service, you must follow specific guidelines. Doing otherwise can look like you falsified 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 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’s no requirement to explain why you’re amending the patient’s record, we recommend doing so, because if something was missing from the documentation at 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.
Something far easier to do on paper than electronically.