Records corrections need to be done wisely. A long list of government entities pour over your patient records, but that doesn't mean you have to be a helpless target. Follow these tips about documenting corrections and additions to your physician's notes to help avoid red flags. Yes, You Can Correct On Behalf of Others Staff sometimes question whether they are allowed to make corrections to a medical record if someone else (i.e., a supervisor) asks them to do so. The answer:
Judge Whether Clarifications Are Too Late
Whether your correction or late entry is helpful or harmful may depend on its timing. "The later after the fact that documentation is added or changed, the less credible it becomes," Adams points out. "The most accurate documentation occurs when it is written at the time of the event."
Changes "should not be common, particularly if time has elapsed," says consultant Rebecca Friedman Zuber in Chicago, Ill. Physicians "that make a lot of corrections in their clinical records will raise questions, should their records be reviewed. It will look like they are writing what they want to have there, not documenting what actually occurred during the delivery of care."
Modifications at almost the same time as the original documentation, however, are usually more acceptable -- especially if your group is making a big push to improve its charting.
"If you're working to improve staff documentation, you should be working concurrently with those staff members, so any documentation changes that result should be pretty contemporaneous with the original entry," Zuber says.
Follow 5 Steps to Successful Changes
Appropriate late entries will only help when you follow the rules. Follow these five steps to make sure your corrections pass muster during review:
Don't Be Scared Away From Corrections
Don't let the caution you must exercise with corrections or additions scare you away from using them altogether.
"We all find times ... when someone else reads what we have written, or we re-read" and it's not as clear as we originally thought, Adams says. "Or we left some key information out of the documentation. Whenever this occurs, additions or corrections to our documentation can occur."
In fact, "sometimes, it is the questions of others that trigger us to improve our documentation," Adams adds. "We suddenly realize that 'what I meant as I was writing did not communicate what I thought it did.'"
Bonus:
And making such changes can spur clinicians to produce better documentation in the future, experts add.