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), the Comprehensive Error Rate Testing (CERT) review contractors, Recovery Audit Contractors (RACs), and Unified Program Integrity Contractors (UPICs). 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 the established recordkeeping principles described above. For example, we must disregard undated or unsigned entries handwritten in the margins of a document. 

Reference: CMS Change Request 8105 (PDF), which updates the CMS Program Integrity Manual (PDF) (Pub. 100-08), chapter 3, section 3.3.2.5.