How to Amend Medical Records: A Guide for Therapists

As a general rule, all services provided to clients that are billed to insurance companies are expected to be documented in the medical record at the time they are rendered. That said, there are situations in which documentation needs to be modified. In these cases, following the appropriate guidelines to make these changes in a compliant manner is extremely important.

In all cases, modifications must be appropriately documented with the original information preserved and the changes clearly noted, including the date of the change and the person making the modification.

Amending medical records

Late entries, addendums, or corrections to a medical record are legitimate occurrences in the documentation of clinical services. A late entry, an addendum, or a correction to the medical record, must bear the current date of that entry and it must be signed by the person making the addition or change.

General guidelines for amending medical records:

• To modify a record, providers should create a new entry in the encounter record with the current date and time. The note should be labeled “Late Entry,” “Correction,” or “Addendum.”
• They should explain the relationship of the note to a previous one, including the reason for the error, and the source of the new information. Records should always reflect who did what.
• Finally, providers should draw a line through the incorrect entry—the text, however, should still be legible. The line-through must be dated and initialed by the person making the change.
• If an omission in a medical record is noticed after a short amount of time and a provider can distinctly remember administering medication or other treatment, a late entry should be made.

When to modify

If the following are not occurring within the context of an audit of medical records, it is appropriate to modify documentation:

• To correct a factual error in the medical record or add missing clinical information: Such an error could have meaningful implications on client care and/or billing.
• To clarify information or address a mistake: If clinically relevant, an addendum can be added to provide additional context or clarification.

When not to modify

• In the context of an audit - this includes creating new records or modifying existing records after a payer request for records has been received.
• Backdating or post-dating entries.
• Adding to existing documentation, except as allowed by the guidelines for late entries, addendums, and corrections.
• To change billing or coding retroactively with the sole purpose of justifying a different or higher CPT code. An addendum must not be used to retroactively establish medical necessity for a service that was not clearly documented at the time of the encounter.
• To address minor typos that do not impact client care.
• If a substantial amount of time has passed since the original date of service: This can raise flags about accuracy and/or motivation from a payer perspective.
• If the addendum creates inconsistencies or conflict relative to other parts of the medical record.

Including a late entry

A late entry supplies additional information that was omitted from the original entry. Late entries should meet the following criteria:

• Be dated with the current date (not the date of the original service).
• Include the signature of the individual making the entry.
• Be written as soon as possible after the service, ideally within 24-48 hours, ensuring the provider has full recall of the omitted details.

Making an addendum

An addendum is used to add information that was not available or was an unintentional error at the time of the original entry. The addendum must:

• Bear the current date and include a reason for the addition.
• Be signed by the individual making the addendum.
• The content of the addendum and the original note - addenda should supplement, not alter or contradict the original note

Making corrections

A correction is a change made to fix an error or inaccuracy in the original documentation. When correcting a medical record:

• Never erase, delete, or overwrite the original entry.
• Document the reason for the correction, date it, and sign.
• Document the correct information as a new entry (clearly titled 'Correction'), referencing the specific date/location of the original error, along with the current date and signature.