By Kris Ravotti, RRT, RCP
Properly maintaining sleep patient medical records is critical to ensuring quality of care and patient safety. These important documents, either in paper or electronic format, contain vital information that fosters continuity in care. They are reviewed extensively by payors, accreditors, Medicare auditors, and lawyers.
When changes are needed, personnel should follow standard medical record documentation amendment practices, especially if your organization submits amended records to auditors. Patient medical records must clearly and permanently identify amendments, corrections, or delayed entries.
Late entries should be documented as soon as possible; backdating is not allowed. Amendments for late entries should be based on recollections of staff directly involved, not information from others.
Additional information can be found in Chapter 3 of the Medicare Program Integrity Manual, which includes guidance on signature requirements (3.3.2.4) and amendments, corrections, and delayed entries (3.3.2.5).
Here are good documentation practices to follow for medical record amendments:
Paper Documents
Use ink, not pencil.
For deletions, use a single line to strike through documentation so the original content is still readable. Add your initials and the date.
Do not use an eraser or correction fluid to remove any original entries.
If adding or changing information, include the new information near the deleted info. If space is a factor, put a symbol (e.g., #,*) and write “correction” on the bottom of the same page or in the page margin.
Electronic Documents
Clearly identify any amendment, correction, or delayed entry.
Provide a reliable means to clearly identify the original content, the modified content, and the date and initials of the person who modified the record.
Strikethrough what needs to be deleted or amended — do not delete it.
If a new entry is required, identify it as a new entry to amend prior documentation.
Training should outline proper procedures for amending patient medical records. Documents should be reviewed often to make sure personnel are continuously following proper documentation amendment procedures.
Bottom Line
Good documentation practices are easily implemented and help ensure your record keeping is accurate, up to date, and consistent, which leads to better inspection/survey results. ACHC is here to help. For more information, email customerservice@achc.org or call (855) 937-2242, ext. 458.
