4) You can make corrections to paper medical records, too Specifically, it may seem obvious, but providers must ensure that what is being represented in the medical record actually took place and is not something that the provider normally does but may not have done for that particular patient. Earn CEUs and the respect of your peers. (f) The author of all medical record entries must be identified by code or employee number, or initials. If an entry is made retrospectively on a paper document, it must reflect the date and time the Ideally, all entries in the medical record should be made in black ink. 3. Editing medical records is evidence that they are inaccurate and makes them impossible to defend. %PDF-1.3 }qO��IܔnB~�>/��.,�ĻrwR�#��'��q*�ZY�Uf[�5s�v���2�ᯰy�o#)=��1��qz��JO. <>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]>>/MediaBox[0 0 612 792]/Contents 27 0 R/Group<>/Tabs/S/StructParents 0/Annots[57 0 R 59 0 R]/ArtBox[0 0 612 792]/CropBox[0 0 612 792]/Parent 260 0 R>> An addendum to a medical record provides additional information that was not available at the time of the original entry. Specify in your record amendment policy the precise information that should be included when a correction, addendum, or late entry is made, such as (a) the date and time of the revision, (b) the name of the person making the revision, (c) a clear explanation of what information is being changed, and (d) the rationale for the modification. See detailed reference at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c03.pdf, This is a link to the First Coast reference (see page 3) 4��E]'Eשo�q�?xO}ԝtq���!��[]�J�=��n ʱ���e8رYj\w�P�� As such, it is important to understand that anything beyond 48 hours could be considered unreasonable. Medicare Comment #2: The medical record cannot be altered. Late Entry: A late entry supplies additional information that was omitted from the original entry. Medical record entries must be completed in a timely manner. For the past few years, without fail, numerous audience members have asked for guidance on the timeliness of entries to the medical record. 2 0 obj Cloned documentation does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information. Timely Completion and Signing of Medical Records One concern I often hear from billing staff has to do with the timely completion of medical records. B. I would like to know what the source was as well, but since the other requests were made in August 2017, and no response seems to be posted, exactly how much credence are we to give this article? Medical Record Entry Timeliness: What Is Reasonable? By Robert A. Pelaia, Esq., CPC However, if a day or more has passed, it is unlikely that the physician can reliably remember exactly what happened. The date of service of the service being amended. All notes should be dated, preferably timed, and signed by the author. Providing evidence if the standard of your care is called into question. Draw a single line through the incorrect information so that it is still legible. For that, the medical record must stand on its own with the original entry corroborating that the service was rendered and was medically necessary. In addition to several other issues, the medical director touched upon the overall timeliness of documentation, medical record addenda, the legibility of medical records and medical record “cloning.” Informing colleagues who may see the patient subsequently and supporting continuity of care. A late entry provides additional information that was originally omitted from the charted documentation. %���� Occasionally, certain entries related to services provided are not properly documented. This includes all types of entries such as narrative/progress notes, assessments, flowsheets, orders, etc. (g) The records shall include, but not be limited to, the following: (i) Name, address and telephone number of the owner or authorized agent. Medical Records Documentation. endobj The record was created a significant time after the clinical care was provided. This is not an easy topic and there is no way to give one answer that will apply to the many scenarios that coders may encounter. �������s�H�W�Ǜ ��wg.� ���3�m���s?�U�P�W}���? Every entry in the medical record must be authenticated by the author – an entry should not be made or signed by someone other than the author. Medicare Comment#4: All entries must be legible to another reader to a degree that a meaningful review may be conducted. This should bear the current date, and include a reason for the addition or clarification of information added to the medical record. Late entries, addendums, or corrections to a medical record are legitimate occurrences in documentation of clinical services. Recording Entries in the Medical Records 1. 3. 2. It’s unreasonable to expect a provider to recall the specifics of a service two weeks after the service was rendered. And preferably, that all entries are identified by the person who made them (initialed/signed) and the information is legible. 2. Clinical records fulfil several important functions. Write the word “ERROR” above or beside the original entry. Medicare Comment #1: Medicare expects the documentation to be generated at the time of service or shortly thereafter. Correction: When making a correction to the medical record, never write over, or otherwise obliterate the passage when an entry to a medical record is made in error. whether in paper or electronic format. Medicare Comment #3: Every note must stand alone, i.e., the performed services must be documented at the outset. You should also contact your local insurance carriers to determine if private insurers follow Medicare's lead on all coding matters. A review of these CMPA cases from 2003–2007 indicate that the most common issues arising from the modification of medical records were: 1. It is important to remember that medical record addenda need to be made to the original medical record, not just to the billing copy. change in clinical state, ward round, investigation) and before the relevant staff member goes off duty. Date. This would make it simple to produce a photoreproduction and ensure that the subsequent copies would be legible. Compliance Tips on Comment #1: Medicare has clearly stated that “reasonable” means 24 to 48 hours. In Good Medical Practice, the GMC says you 'must record your work clearly, accurately and legibly.' Did a little bit of poking around but all I was able to locate is the following below but I will call out that it doesn’t specify the information listed above that we are all looking for. Sometimes services that may have been provided were not properly documented. It is not reasonable to expect that a provider would normally recall the specifics of a service two weeks after the service was rendered. Would you provide reference for Medicare Care statement, please. All documentation in the medical record must be specific to the patient and her/his situation at the time of the encounter. Medical record addenda must be properly identified and reference must be made to the original note being amended. An entry should never be made in advance. 2. Copying for re-use of data: A clinician may copy and past entries made in a patient’s record during a previous encounter into a current record as long as care is taken to ensure that the information actually applies to the current visit, that applicable changes are made to variable data, and that any new information is recorded. These changes to the EHR should always be made available to the user of the record unless such changes are detrimental (e.g., incorrect information was … 1 0 obj An entry should never be made in the Medical Record in advance of the service provided to the patient. Cloning also occurs when medical documentation is exactly the same from patient to patient. Like late entries, it should also bear the current date, along with the reason for the addendum. Could you please provide the reference for Medicare statement? 2. Addendums to existing medical records must be made in a timely manner. A late entry, an addendum or a correction to the medical record, bears the current date of that entry and is signed by the person making the addition or change. 2014-12-01. We are looking for thought leaders to contribute content to AAPC’s Knowledge Center. Those responsible for coding and/or entering charges need to be cognizant of the timeliness of medical record completion. The absolute minimum standard for accurate medical record keeping requires that records be legible (preferably not hand-written and ideally digital) and contain: Patient demographics, such as name, date of birth, and contact details. 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