Incorporate updates, addendums to medical records while maintaining compliance

Why This Topic Matters

Accurate medical record maintenance affects compliance, audit readiness, and the integrity of billed services. The article helps readers understand the broad documentation practices and compliance concerns that can trigger review or raise concerns during audits.

Article Sections

1. Introduction

   Introduces the shift to electronic health records and the compliance concerns associated with record modifications and documentation accuracy.

2. Types of EHR modifications

   Describes major categories of record updates and the general purpose of each type of change in a health record.

3. CMS’ recordkeeping principles

   Summarizes general recordkeeping expectations for paper and electronic records and notes the involvement of contractors and oversight entities.

4. Falsified documentation

   Reviews documentation patterns that may raise concerns during audit and compliance review, including improper record alterations and related behaviors.

5. Best practices

   Offers broad compliance-oriented guidance for handling documentation issues and escalating concerns within a practice.