Courtesy of MedPro Services | Laura M. Cascella, MA
Altering documentation in patient records can have serious consequences, including allegations of fraud and professional misconduct — and it also can make malpractice claims difficult to defend. Yet, mistakes happen and situations undoubtedly will occur that require healthcare providers to make corrections, addendums, or late entries in patient records.
Because the majority of healthcare organizations have transitioned to electronic health records (EHRs) in the last decade, policies and procedures for amending records should reflect that change. In principle, many of the same standards for amending paper records apply to EHRs, such as not obscuring the original documentation, making timely corrections, and signing all entries. What differs in EHRs is the interface (including how the information is displayed and recorded), as well as the ability of the system to track user actions through metadata and audit trails.
To start, healthcare organizations should devise and document a clear process for amending patient records as part of their overall documentation policies and procedures. This process will help guide providers and staff and reinforce a consistent approach to making corrections. Other tips for amending electronic records include the following:
- Make sure your organizational policies for revising patient records comply with federal and state laws. Some states may have specific regulations related to record amendments.
- Determine whether your EHR system has a specific process or workflow for corrections, addendums, or late entries in records. Can the system track any modifications made to records after the original entries?
- Ensure that corrections, addendums, and late entries do not overwrite the original content, and that the original information is easily accessible.
- Verify that your EHR system has a way to clearly indicate or “flag” which records have been revised.
- Specify in your record amendment policy the precise information that should be included when a correction, addendum, or late entry is made, such as (a) the date and time of the revision, (b) the name of the person making the revision, (c) a clear explanation of what information is being changed, and (d) the rationale for the modification.
- Require notification to the original author of the content about the correction, addendum, or late entry so he/she can verify that the amendment is necessary (if the person making the revision is not the same person who authored the original content).
- If an amendment is not within the same record entry as the original content, make sure the original content also clearly notes that an amendment exists and how the user can locate it.
- Specify in your record amendment policy the appropriate timeframe for making corrections, addendums, and late entries. Delays in revisions might diminish the credibility of the changes.
- Prohibit providers and staff from amending patient records that have been requested by an attorney or government agency or are associated with a pending or ongoing malpractice suit.
- Ensure that your record amendment policy strictly prohibits falsifying information in patient records, such as changing dates, deleting information, or adding nonfactual information.
- Educate providers and staff about documentation amendment procedures and the possible consequences of deliberate or inadvertent record falsification. Make sure providers and staff are aware of how the EHR system works and the types of information that metadata and audit trails will capture.
- Routinely audit corrections, addendums, and late entries in the EHR to ensure that providers and staff are complying with organizational documentation policies.1
To further assess your organization’s policies related to EHR documentation, use MedPro’s Electronic Documentation checklist.
1 Centers for Medicare & Medicaid Services. (2017). Chapter 3: Verifying potential errors and taking corrective actions. In Medicare Program Integrity Manual (Publication No. 100-08). Retrieved from www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS019033.html; Samaritan, G. (2013, May 29). Correcting EHR errors without getting in trouble. Medscape. Retrieved from www.medscape.com/viewarticle/804731; Sheber, S. (2012, August 29). New toolkit provides guidelines for EHR amendments. Journal of AHIMA. Retrieved from http://journal.ahima.org/2012/08/29/new-toolkit-provides-guidelines-for-ehr-amendments/