Inpatient Facility Coding & Compliance Alert

Question: One of our physicians made mistakes on several charts and printed out new documentation to replace the old notes. Our office manager isn’t comfortable with this. Can you advise?

Arkansas subscriber

Answer: Although it is legal to amend your records, you cannot simply replace the original documentation, because payers could consider that “record tampering.”

As long as the doctor actually remembers the information, or reads notes or other written information that triggers their memory of the additional information, he can add information at any time. Follow these steps to make sure your corrections will pass a review:

1. Cross out old information rather than deleting it. If you are correcting an incorrect statement in the record, you should draw a line through the statement and put the word “error” next to it. Then sign it with the date. The original information must still be readable and included in the record. Use just a single line to cross it out.

2. Title the late entry. Never try and make a late entry appear like it was there all along. Be sure to clearly mark the correction or supplementation as a late entry with a title such as “Addition to record made on Dec. 15, 2015 by Steve Smith, MD.”

3. Include signature and date. Any late entry should include its date, and corrections or additions to documentation should ideally be made by the documentation’s original author. That person should sign the correction as well as dating it.

4. Add the reason. It’s a good idea to jot down the purpose of the entry, such as “clarification.” It’s also helpful to indicate the source of the additional information, such as based on notes jotted during the visit.

5. Remember hard copies. If you make a correction in the electronic health record and there is also a hard copy printed from the electronic record, the hard copy must also be corrected.