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Adding omitted information or making corrections in the medical record is a fact of life for therapists. Some of the more common questions we hear regarding medical documentation are:
- What is new documentation used to add information to the original entry called?
- What timeframe is considered to be most appropriate for making a late entry in a medical record?
- What is a medical addendum?
- What is required in case of making a late entry?
- What is the proper way to document when a note is entered late?
- Late entry note example
Lets take a dive down to a deeper level and answer some of these questions but first lets step back and look at the big picture. The National Library of Medicine has a wealth of valuable information. In it you will find this article: Managing the Life Cycle of Electronic Clinical Documents (clicking this link and other links on this page may direct you to external websites not controlled by us). The discussion content lists 3 examples illustrating various documentation models, this content and more within it can help shed more light on macro-understanding of things to consider when amending medical documentation. It was published in 2006 but still a great read. Many things this article doesn’t discuss is insurance requirements, proof audit requirements, and several others.
TheraPlan EMR recognizes that your medical documentation serves as the backbone to your practice – authorizations, payments and the integrity of your practice all rely on the accuracy and quality of your medical documentation. With any practice it’s important to stress to all providers to ensure their medical documentation is done right from the start, but it’s also important to establish best guidelines to amending medical documentation after the fact.
Our therapy documentation templates are built around the proper way to edit therapy medical documents. Rest assured that therapists completing their documentation inside TheraPlan use the right process each time, every time.
This blog post should help everyone understand more about amending medical documents. If you are a Therapy Service Provider looking for an EMR that will help you easily transition your practice to TheraPlan today and begin editing your therapy documentation the right way, contact us for more information or review our pricing.
Keep reading below to learn more about amendments, corrections, and late additions. Did you know you can refer a friend and get $50*.
Lets dig in! It’s important to note that all amendments should be done when the therapist still has total recall of the visit. Industry practice generally says this is within about 48 hours. There are three types of additions to medical records – late entry, addendum and correction.
Late entries are done when you need to add information that was omitted from the original entry. You must add late entries, label them as such, and sign the late entry with your name and date it on the day you added the late entry. Late entries should only be done by the person who treated the patient as they are the only person with total recall of that visit. An example of a late entry may be “It was noted that the patient was lethargic during the visit. John Smith 06/13/2019.”
Addendums are done when a provider wants to attach a note or comment to the medical record that was not available at the time of a visit. For example a speech therapist may have a visit with a child. During that visit they indicate the child doesn’t seem to be hearing appropriately and should visit the pediatrician as soon as possible to check for fluid build-up in the ear. The next day the patient reports that the pediatrician did find an ear infection. The therapist could then add an addendum indicating “Patient saw pediatrician and did report an ear infection and fluid build-up. John Smith 06/13/2019”
Corrections are done for true errors made in the medical record that the provider wants to correct. Corrections should never completely remove what was there before. It should be very clear what the original text was – so just use a strike-through over the inaccurate information. A correction should indicate the current date (date correction was made), time, reason for the change and the initials of the person making a correction. A correction would be done if the therapist loaded a note with a wrong date of service or perhaps indicated the wrong age for the patient.
The Centers for Medicare and Medicaid(CMS.gov)has lots of great resources as well. One of them is the Documentation Matters Toolkit. Spend time reviewing it and if you have 91 minutes watch their YouTube video Your Medical Documentation Matters we encourage you to do so.
Insurance companies may refuse to consider addendums in an audit. For example – if medical records are requested and sent and something is denied because of it – it is not appropriate to add it and try to send in the records again. Because of policies like these it is very important that your medical records are accurate and complete from the start. Addendums and corrections serve their purpose but they should not be a crutch and should be few and far between.
A good therapy billing company will be able to have those conversations with you ahead of time and ward off any potential surprises dealing with rejected addendums.
