E/M Weekly Tip: Completing Documentation

Providers are encouraged to enter all relevant documents and entries into the medical record at the time they are rendering the service. Occasionally, upon review a provider may discover that certain entries, related to actions that were actually performed at the time of service but not properly documented, need to be amended, corrected or entered after rendering the service.

Recordkeeping Principles Widely Accepted
Regardless of whether a documentation submission originates from a paper record or an electronic health record, documents containing amendments, corrections or addenda must:

  1. Clearly and permanently identify any amendment, correction or delayed entry as such; and
  2. Clearly indicate the date and author of any amendment, correction or delayed entry; and
  3. Not delete but instead clearly identify all original content 

Reminder
Documentation should not be added to meet billing requirements. For further information regarding entries in medical records (amendments, corrections and addenda) please visit the CMS Program Integrity Manual (Pub. 100-08) (PDF, 598 KB), Chapter 3, Section 3.3.2.5.