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Are Corrections/Supplements to Clinical Records Illegal
or Unethical?
Elizabeth E. Hogue, Esq.
Office: 877-871-4062
Fax: 877-871-9739
E-Mail:
ElizabethHogue@ElizabethHogue.net
Many providers are appropriately
conducting a variety of retrospective reviews of patients’ clinical records.
These audits may reveal incomplete or inaccurate records. The records must be,
therefore, corrected or supplemented, if possible, in order to help ensure
quality of care, meet applicable regulatory requirements, and avoid allegations
of fraud and abuse.
When managers ask clinicians to
assist them with this process, however, some staff members still conclude that
they are being asked to engage in illegal and/or unethical conduct. On the
contrary: it is absolutely essential to correct and/or supplement records
whenever it is appropriate to do so.
Specifically, clinicians may
supplement and/or correct patients’ clinical records under the following
circumstances:
- Clinicians
have a clear recollection of the information; and/or
- There is a
writing that serves as the basis for clinicians’ supplements and/or corrections.
Supplements to patients’ clinical
records must include:
- The date
the entry is actually made;
- The
information that was originally omitted and the date on which the information
was available; and
- The
signature and title of the employee who supplements the record.
Corrections to patients’ clinical
records must be made by drawing a solid line through mistakes. Providers’
internal policies and procedures may also require staff to write the word
“error” in relation to the information through which a line has been drawn.
If correct information is also added
to the record, clinicians must write the correct information in a location
specified by internal policy and procedure. The date on which the correction
was made and the signature or initials of clinicians who make corrections will
also be written with each correction. Clinicians may not use correction fluids
or erasures when making corrections.
Providers should develop and
implement polices and procedures that make it clear that staff members are
obligated to correct or supplement records of care provided under the
circumstances and in the manner described above. Internal policies and
procedures may also provide for discipline of staff members who fail to do so.
Changes to clinical records are
consistent with applicable national standards of care and are essential for all
of the reasons stated above. Staff who fail to make appropriate changes are not
acting in their own best interests or the best interests of patients and
providers.
©Copyright, 2008. Elizabeth E.
Hogue, Esq.
No portion of this material may be
reproduced in any form without the advance written permission of the author.
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