Medical Documentation: What You Need To Know About Recordkeeping, Amendments, and Delayed Entries
All services are expected to be documented in the medical record at the time they are rendered. If certain entries related to provided services are not properly documented, those entries will need to be amended, corrected, or entered after rendering the service. To find out more about the principles of medical documentation, please keep reading.
Every health care service rendered to a patient should be documented in the patient's medical record at the time the service is rendered. However, there are situations when services that may have been provided were not properly documented. In such situations, the documentation will need to be amended, corrected, or entered after the service is rendered based on the existing recordkeeping principles.
Recordkeeping principles set by CMS
It does not matter whether it is a paper record or an electronic health record, any documents containing amendments, corrections or addenda must:
· Clearly and permanently indicate the amendment, correction, or delayed entry in the document
· State, very clearly, the date and author of the amendment, correction, or delayed entry
· Precisely identify all original content, without deletion
Paper medical records
There are special considerations for paper medical records. When correcting a paper medical record, these are how you can neatly keep to the recordkeeping principles:
· Use only a single line strike through when making corrections so the original content is still readable
· After making an alteration, you must sign and date the revision
Please note that amendments or delayed entries to paper records may be initialed and dated if the medical record contains real evidence that associates the provider’s initials with their full name.
Electronic health records (EHR)
The general principles stated above remain fundamental and necessary for recordkeeping, but medical records within an EHR requires special considerations. When records sourced from electronic systems contain amendments, corrections, or delayed entries, the following principles must be followed:
· The record must distinctly identify any amendment, correction, or delayed entry
· It must provide a reliable means to clearly identify the original content, the modified content, and the date and author of each modification of the record
Please note that providers must comply with the recordkeeping principles.
In conclusion, you can make your medical documentation and recordkeeping easy by calling on WCH. With over 19 years of experience in medical record auditing, we are your best ally in making sure that you get the best from your practice while being compliant with all the rules and regulations.
WCH understands recordkeeping and billing processes from A to Z, and our certified auditors and coders work with doctors across all medical specialties. Contact us!