Correcting Medical Records

March 4th, 2013

Every doctor has experienced it: the moment when he or she is reviewing a case file, and realized they have omitted a key piece of information. Just as often, a patient returns to the office with the revelation that they were incorrect about a symptom, or past condition, or some other key information regarding their medical history. Now, what can you do? From the moment that pen touches paper, or fingers hit the keyboard, the document in front of you becomes a legal record.

Luckily, you can amend the record. There is a right way to do this and there is most definitely a wrong way. Do not, under any circumstances, obscure the original information. If you are still keeping paper records, strike through the wrong information with a single pen line, add in the correction or amendment with a new document or (if the information is minor) a signed and dated note in the margin.

The same principal applies to electronic records. Make sure that you indicate which information was original, and which is the addendum. Make sure you electronically date and sign the record changes.

In their guidelines, the CMS Manual System states:

Regardless of whether a documentation submission originates from a paper record or an electronic health record, documents submitted to MACs, CERT, Recovery Auditors, and ZPICs containing amendments, corrections or addenda must:


1. Clearly and permanently identify any amendment, correction or delayed entry as such, and
2. Clearly indicate the date and author of any amendment, correction or delayed entry, and
3. Not delete but instead clearly identify all original content.

Correcting medical records legally is not rocket science, but it does take finesse and know-how. KLA Healthcare Consultants can help you navigate the regulations.

Please contact us with any questions or comments you may have regarding correcting medical records legally.

Tags: Medical Records

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