OASIS Alert

"This is a topic of greater concern given the number of entities that are now looking at home health claims," warns Judy Adams with Adams Home Care Consulting in Chapel Hill, N.C. "And the scrutiny is just beginning!"

"Record tampering undermines a clinician's credibility in the event of litigation," warns a guidebook on medical documentation by the University of North Texas. "It is important not to jeopardize the integrity of a patient's medical record by using a questionable correction method."

Rumor: Some home care staff believe they are not allowed to make corrections to a medical record if someone else (i.e., a supervisor) asks them to do so.

Truth: It is perfectly OK for a clinician to make changes to the record at another person's request, Adams notes. That is, as long as the clinician actually remembers the information, or reads notes or other written information that triggers their memory of the additional information, adds Washington, D.C.-based attorney Elizabeth Hogue.

Often such correction requests will be made of staff in the course of internal quality reviews, notes regulatory consultant Rebecca Friedman Zuber in Chicago, Ill. Examples can include during initial supervisory review of the assessment and plan of care or during quarterly record reviews, Zuber says.

1. Cross out, don't black out. 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, Zuber counsels. Then sign or initial it (depending on your agency's policy) and put the date.

Plus: "The original information must still be readable and included in the record," Adams tells Eli. Use just a single line to cross it out.

2. Don't forget the title. The cardinal sin of making corrections is failing to note the late entry. Be sure to clearly mark the correction or supplementation as a late entry, Adams advises.

3. Include a date and signature. Any late entry should include its date, Hogue says.

4. Don't be stingy. It's a good idea to jot down the purpose of the entry -- for example, clarification, Adams suggests. And "it is also helpful to indicate ... the source of the additional information, such as based on notes jotted during the visit," she says.

5. Consider these issues for computer records. When you correct an electronic record, remember that the original information must remain in the record, advises the University of Michigan Health System in its medical documentation policy. And "in situations where there is a hard copy printed from the electronic record, the hard copy must also be corrected."

Note: UNT's guidebook is at www.hsc.unt.edu/policies/QuAssure/Clinical%20Documentation&ComplianceManual042704.pdf. The U of M policy, which includes guidance on corrections, late entries, addendums/clarifications, and more is online at www.med.umich.edu/newclinicians/med_rec.htm (search for "correction"). For a free link to and PDF copy of these documents, e-mail editor Jan Milliman at janm@codinginstitute.com with "Corrections" in the subject line.