The Legal Requirements
by Cheryl Nash
Mistakes, we all make them occasionally, but what to do when the mistake is in a patient’s medical record? As with all things in this business, there are some legal requirements when a correction needs to be made. First, we need to identify what type of correction and understand the differences between them. There are addendums, late entries and corrections.
An addendum is utilized to provide additional information that was not available at the time the original documentation was entered. This should bear the current date, and include a reason for the addition or clarification of information added to the medical record. This should be entered in a timely fashion.
A late entry provides additional information that was originally omitted from the charted documentation. This entry will have the current date, and is added as soon as possible. This should only be done if the individual providing the information has total recall of the details in the added information.
A correction is exactly as it sounds. For example, the record noted ‘right’ when it should have stated ‘left’. When making a correction, you should never write over the original entry. Instead, you should strike out the original entry with a single line allowing the original information to still be legible. Sign and date the strike out, being sure to state the reason for the correction either above or in the margin, and reference back to the original entry.
Correcting electronic records will follow the same standard of tracking on both original and corrected entries with current date, time, and reason for making a change. If a hard copy is generated, both records will need to reflect the correction.
All of the changes listed above require a separate entry, signed and dated by the individual responsible for making the change, with a reasonable explanation of why the change is being made.
Falsification of documentation while typically not done maliciously can happen due to a lack of knowledge on the rules. Some types of changes that constitute falsification are: Creation of new records when requested, back-dating , post-dating, and pre-dating entries, writing over, or adding to documentation without following the formal guidelines as outlined above. Unfortunately falsifying documents is considered a felony offense and can carry some large penalties.
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