MDS Alert
Avoid Late Entry Red Flags
When does a clarification hurt instead of help? Don't let the fear that your medical records won't hold up under scrutiny lead you to overindulge in documentation additions. If you correct or add to every medical record that gets reviewed, you may come to regret it. "With regard to supplementing documentation in preparation for ... audits, providers certainly need to proceed with care," advises Washington, D.C.-based attorney
Providers "should not be routinely making revisions to clinical records prior to sending them off" in response to an advance development request (ADR), counsels regulatory consultant Rebecca Friedman Zuber in Chicago, Ill. "It will look like they are writing what they want to have there, not documenting what actually occurred during the delivery of care," cautions Zuber.
When correcting or adding to the medical record, "the greatest error of all is to write information just because someone told you to do so, but you have no memory of the information," stresses consultant Judy Adams in Chapel Hill, N.C.
Bottom line:
"Making up information that actually never happened is fraudulent documentation and can never be justified," Adams maintains.How Late Is Your Late Entry?
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," Zuber agrees. Remember, "changes ... should be made just to clarify existing entries or to deal with contradictory information in the record," Zuber adds.
Don't Get Scared Off of 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 observes. "Or we left some key information out of the documentation," she adds. "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 relates. "We suddenly realize that 'what I meant as I was writing did not communicate what I thought it did.'"
And making such changes can spur clinicians to produce better documentation in the future, experts add.
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