Modifying the Patient Record: Corrections,Revisions, Additions, and Addenda

Biggest questions that most of the medical transcription service organization come across to find an appropriate way to process corrections, revisions, additions, and addenda

The rules to modifying the Patient Record should be strong foundation for the enterprise seeking to develop policies and procedures. In order to ensure the admissibility of the medical record as evidence, the enterprise must first establish policies and procedures that address

• Author authentication
• Medical record access control
• Medical record archiving and retention
• Medical record security
• Medical record disaster recovery policies and procedures

By establishing controls over the creation of medical records, enterprises can ensure the nonrepudiation of corrections, revisions, additions, and addenda made in the normal course of business.

Ultimately, by controlling the how, who, where, and when of creating the medical record, the enterprise establishes the methodology for performing valid corrections, revisions, additions, and addenda.

The best practices of a health care enterprise can develop an effective and valid policy and procedure for the correction, revision, addition, and addenda of health information contained within the medical record.

Though it is true that no single rule that addresses medical record correction and amendment exists, enough guidance is available to allow health care providers to develop a workable policy and procedure to address the creation of valid medical record corrections and amendments.