Tips for Amending Electronic Health Records
Laura M. Cascella, MA, CPHRM
Altering documentation in patient records can have serious consequences, including allegations of fraud and professional misconduct — and it also can make malpractice claims difficult to defend. Yet, mistakes happen and situations undoubtedly will occur that require healthcare providers to make corrections, addendums, or late entries in patient records.
Most healthcare organizations use electronic health records (EHRs), so policies and procedures for amending records should align with system-related factors, such as how information is entered and displayed as well as the ability of the EHR system to track user actions through metadata and audit trails.
To ensure a consistent approach and reduce risks associated with altered documentation, consider the following strategies:
- Devise and document a clear process for amending patient records, and make sure it is included in organizational documentation policies. The process will help guide providers and staff members in a standardized approach to making corrections.
- Make sure organizational policies for revising patient records comply with federal and state laws. Some states may have specific regulations related to record amendments.
- Specify in the record amendment policy the precise information that providers should include 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 was changed, and (d) the rationale for the modification.
- Develop a process for managing patient-requested changes to health records. Under HIPAA, patients have the right to request changes to their records if they believe the records contain incorrect, incomplete, or inconsistent information.1 Healthcare organizations should have a policy and process for assessing and responding to these requests within the HIPAA-specified timeframe.
- Determine whether the EHR system has a specific process or workflow for corrections, addendums, or late entries in records. Can the system track any modifications made to records after the original entries?
- Ensure that corrections, addendums, and late entries do not overwrite the original content, and that the original information is easily accessible.
- Verify whether the EHR system has a way to clearly indicate or “flag” which records have been revised.
- Require notification to the original author of the content about the correction, addendum, or late entry so they can verify that the amendment is necessary (if the person making the revision is not the same person who authored the original content).
- Ensure that if an amendment is not within the same record entry as the original content, the original content clearly notes the amendment and how the user can locate it.
- Specify in the record amendment policy the appropriate timeframe for making corrections, addendums, and late entries. Delays in revisions might diminish the credibility of the changes.
- Prohibit providers and staff members from amending patient records that an attorney or government agency has requested or that are associated with a pending or ongoing malpractice lawsuit.
- Ensure that the record amendment policy strictly prohibits falsifying information in patient records, such as changing dates, deleting content, or adding nonfactual information.
- Educate providers and staff members about documentation amendment procedures and the possible consequences of deliberate or inadvertent record falsification. Make sure they are aware of how the EHR system works and the types of information that metadata and audit trails will capture.
- Routinely audit corrections, addendums, and late entries in the EHR system to ensure that providers and staff are complying with organizational documentation policies.2
For more guidance related to EHR documentation, see MedPro’s Electronic Documentation checklist.
Endnotes
1 45 CFR § 164.526
2 Centers for Medicare & Medicaid Services. (2021). Chapter 3: Verifying potential errors and taking corrective actions. In Medicare Program Integrity Manual (Publication No. 100-08). Retrieved from www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS019033; Samaritan, G. (2013, May 29). Correcting EHR errors without getting in trouble. Medscape. Retrieved from www.medscape.com/viewarticle/804731; American Health Information Management Association. (2012). Amendments in the electronic health record: Toolkit. HIM Body of Knowledge. Retrieved from https://bok.ahima.org/; Heath, S. (2024, January 3). Breaking down patient requests for EHR, medical record corrections. Xtelligent/TechTarget. Retrieved from www.techtarget.com/patientengagement/feature/Breaking-Down-Patient-Requests-for-EHR-Medical-Record-Corrections
