Late Entries, Addendums and Corrections
November 18, 2020
by Sean Weiss, Partner & VP of Compliance
I get lots of questions on how to fix provider documentation that is lacking information. Late entries, addendums, or corrections are all legitimate occurrences.
Late Entry: A late entry supplies additional information that was omitted from the original entry. It is written only if the person documenting has total recall of the omitted information and signs the late entry.
Addendum: An addendum is used to provide information that was not available at the time of the original entry.
Correction: When making a correction to the medical record, it is important to never write over or otherwise obliterate the passage when an entry to a medical record is made in error. Draw a single line through the erroneous information, making sure that the original entry is legible. Correction of electronic records should follow the same principles of tracking both the original entry and the correction with the current date, time, reason for the change and initials of person making the correction.
Deliberate falsification of medical records is a felony.
Examples of falsifying records include:
- Creation of new records when records are requested
- Back-dating entries;
- Post-dating entries;
- Pre-dating entries;
- Writing over; or
- Adding to existing documentation (except as described in late entries, addendums and corrections)
What to do next…
- If you need help with an audit appeal or regulatory compliance concern, contact us at (800) 635-4040 or via email at firstname.lastname@example.org.
- Read more about our: Total Compliance Solution
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