Amending the Medical Record

by  Shannon O. DeConda, CPC CPC-I CEMC CEMA CPMA CRTT
Apr 8th, 2016 - Reviewed/Updated Aug 16th

A medical record is a legal document and therefore there is a right way to modify a record and certainly a wrong way as well. All modifications and addendums must follow the guidelines whether it is the provider or ancillary staff that are modifying their own entries. Addendums may be corrective in nature or may need to address information or findings not available at the time the original documentation was created. Addendums may be subject to a higher level of scrutiny in evaluation of the use and frequency of addendums by the provider.

Amendments to the medical record are not as relevant since we have moved into the EHR era. When we think of modifications, we used to think of a single line, initial, and dating of the change (which would still be applicable to those who are still handwriting and dictating their documentation). EHR changes should be tracked and notated, and if the EHR does not have the capacity to include such notations and tracking then the addendum should include a heading to properly identify that portion of the entry as a true addendum to the medical record.

Addendums should not be used as a way in which the record is modified in order to support documentation guidelines on a consistent basis. Of course, this also does not mean that should the provider fail to include certain elements from time to time that an addendum would not be acceptable. There are specifics that must be adhered to in order for an addendum to meet CMS rules.

Within the Internet Only Manuals (IOM) of CMS the Program Integrity Manual includes the principles for appropriate record keeping. These principles address the creation of addendums and corrections to medical record, and include 3 primary principles. When reviewing these principles it becomes quite clear as to how CMS will validate the use of addendums. The 3 Recordkeeping Principles are:

1. Clearly and permanently identify any amendment, correction or delayed entry as such,

2. Clearly indicate the date and author of any amendment, correction or delayed entry, and

3. Do not delete but instead clearly identify all original content

These principles are relevant to any type of medical record whether paper or electronic formats.

When modifying a record be sure and properly distinguish amendments as such and then keep the content separated from the original content. Recently when auditing a hand written chart the provider indicated that an addendum had been created, but there was not ability to separate out that information.CMS has specifically added to the Recordkeeping Principles additional guidance regarding the EHR amendments. The principles additionally include:

a. Distinctly identify and amendment, correction, or delayed entry, and

b. Provide a reliable means to clearly identify the original content, the modified content, and the date and authorship of such modification of the record.

These principles do not vary much from the standard principles as they still require the distinct separation of the content. It is noteworthy that CMS does not state that "click tracking" is an acceptable distinction. Many EHR vendors/sales reps fall back on the click tracking capabilities for meeting gray areas in their product, but note that it may not be a recognized process with CMS. The note must have separate comments and headings indicating it is the addendum.

Regardless of the type of medical records a practice uses, education should be provided to all staff on these principles and a policy should be adapted specific to the type of record the practice uses, any type of special addendum/modification tools by the EHR system, reasons for which addendums/modifications should be created, and the timeliness of any such amendments.