General Question for the Week of July 31, 2017

Question:

What Medicare rules must be followed to correct a paper medical record?

Answer:

According to the Centers for Medicare & Medicaid Services (CMS), the following principles apply:

• Use a single line strike through so the original content is still readable.
• The author of the alteration must sign and date the revision.

Amendments or delayed entries to paper records must be clearly signed and dated upon entry into the record. They may be initialed and dated if the medical record contains evidence associating the provider’s initials with their name. For example, if the initials match the first and last name of the practitioner documented elsewhere in the medical records including typed or written identifying information, the reviewer shall accept the entry.