General Surgery Coding Alert - 2015 Issue 44
Reader Question: Don't Take Chart Amendments Lightly
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Article Overview
This reader question discusses how medical practices should handle corrections, late entries, and other amendments to patient documentation. It is aimed at physicians, office managers, coders, and compliance staff who need to preserve record integrity while reducing audit and payer risk. The article covers general documentation maintenance guidance, including preserving original entries, labeling additions appropriately, and keeping electronic and paper copies consistent.
Why This Topic Matters
Documentation changes can affect audit defensibility, compliance, and payer review. Understanding proper amendment handling helps practices avoid record integrity problems and maintain accurate patient records.
What You Will Learn
- How medical record amendments are generally handled in a compliance context
- Why original documentation should remain part of the record
- What makes a correction or late entry easier to distinguish
- Why both electronic and printed versions of a record may need to be updated
Who Should Read This
- Physicians
- Office managers
- Medical coders
- Compliance staff
- Health information management professionals
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