Use caution when altering medical records

January 21, 2010

Amendment of a medical record can be a good thing, but be sure to complete your records correctly the first time.

Key Points

Amendment of a medical record can be a good thing. Reviewing your records to check for accuracy and completeness and taking the time to amend them is common and commendable.

Once a lawsuit has been filed or an attorney has requested records, it's too late. Perhaps you receive a request for records, review your documentation, and see that some fact is omitted or some entry is inaccurate. You quite innocently think that you can "improve" the record. Don't do it.

What should you do if you discover an omission? Suppose you review your earlier progress note and discover that you forgot to state that you made an appointment for a patient x-ray. Adding a note shows that you were careful enough to review your notes and concerned enough to add the missing information.

The proper way to amend records:

What should you do if you discover an error in your notes? Show that you are conscientious and concerned by writing a good correction.

Using correction fluid to cover the original note, erasing, or obliterating any documentation in the record is unacceptable and would be characterized in court as an attempt to hide the facts.

The proper method to correct an entry is to follow the two steps listed above and additionally:

This method for making corrections also applies to dictated notes.

With electronic medical records, the computer program must show the dates of the original notes and the dates of any changes or new entries.

You can be sure that any alteration will be detected by experts on handwriting, paper, ink and pen. The impact of improper alterations:

The author is a health law attorney in Mt. Kisco, New York, and a Medical Economics consultant. She may be reached at lj@bestweb.net. Malpractice Consult deals with questions on common professional liability issues. Unfortunately, we cannot offer specific legal advice. If you have a general question or a topic you'd like to see covered here, please send it to memalp@advanstar.com
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