Q&A: Adding notes to patient records

October 3, 2008

How can I add additional information to a patient's record without risking suspicion if I'm ever sued and those records are scrutinized?

Q: In reviewing a patient's record before a follow-up appointment, I remembered a detail that I forgot to jot down during the last visit. How can I add that information without risking suspicion if I'm ever sued and those records are scrutinized?

A: Add the note someplace where it will be obvious and legible instead of cramming it in wherever it will fit. You should always use the current date-never backdate-and note that you're adding the information late, and if possible, explain why you didn't originally include it. Make your addition as soon as possible, and never alter any record that has already been requested.