Entries in Medical Records: Amendments, Corrections and Addenda

Entering information into patients’ medical records in a timely manner is important for many reasons. The Centers for Medicare & Medicaid Services (CMS) provides some guidance regarding what is considered 'timely,' for Medicare purposes.

We strongly encourage all health care providers to enter information into the patient’s medical record at the time the service is provided to the patient; that is, contemporaneously. 

CMS recently published 'established recordkeeping principles' to provide further guidance regarding the timeliness of entries in medical records. These principles apply to all Medicare contractors that review medical records, including: Medicare Administrative Contractors (MACs), to include Palmetto GBA; the Comprehensive Error Rate Testing (CERT) review contractor; Recovery Audit Contractors (RACs) and Zone Program Integrity Contractors (ZPICs). In all cases, regardless of whether the documentation is maintained or submitted in paper or electronic form, any medical records that contain amendments, corrections, or addenda must:

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

For paper medical records:

  • Making corrections, in keeping with these principles, generally entails using a single line strike-through  so the original content is still legible
  • The author of the alteration must sign and date the revision
  • Amendments or delayed entries must also be signed and dated by the author upon entry

For electronic medical records:

  • Amendments, corrections, and delayed entries must be distinctly identified as such
  • The record must provide a reliable means of clearly identifying the original content, the modified content, and the date and author of each modified record

Medicare contractors, including Palmetto GBA, cannot consider entries in medical records that do not comply with these established recordkeeping principles, as described above; for example, we must disregard undated or unsigned entries handwritten in the margins of a document. 

Reference:

Contact Railroad Medicare

Email Railroad Medicare

Contact a specific Railroad Medicare department

Provider Contact Center: 888-355-9165

IVR: 877-288-7600

TTY: 877-715-6397

Other Palmetto GBA Sites

Palmetto GBA Home

DMEPOS Competitive Bidding Program

Jurisdiction J Part A MAC

Jurisdiction J Part B MAC

Jurisdiction M Part A MAC

Jurisdiction M Part B MAC

Jurisdiction M Home Health and Hospice MAC

MolDX

National Supplier Clearinghouse MAC

PDAC

RRB Specialty MAC Providers

RRB Specialty MAC Beneficiaries

Anonymous

 

Click to Chat Now