late entry to electronic medical record

Do late entries or addendums have to be signed and dated by the physician again if the original note was signed already?

Example:

Progress note
Electronically signed by Dr. Jones 1/1/2016

Addendum to Progress note by Dr. Jones:
Patient referred to HH for insulin injections.

No additional signature required for the addendum?

Comments

  • edited May 2017
    It must have a signature
    ​ (or initials if appropriate per below)​
    and date. See the larger text with *bold *below
    ​ for the direct answer​
    .
    ​ Sorry for the length of the excerpt, but the whole section seemed
    relevant.​


    https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/pim83c03.pdf

    ​Medicare Program Integrity Manual
    Chapter 3 - Verifying Potential Errors and Taking Corrective Actions​


    3.3.2.5 - Amendments, Corrections and Delayed Entries in Medical
    Documentation
    (Rev. 615, Issued: 10-02-15, Effective: 10-02-15, Implementation: 11-02-15)
    This section applies to MACs, CERT, Recovery Auditors, and ZPICs, as
    indicated.

    A. Amendments, Corrections and Delayed Entries in Medical Documentation
    All services provided to beneficiaries are expected to be documented in the
    medical record at the time they are rendered. Occasionally, certain entries
    related to services provided are not properly documented. In this event,
    the documentation will need to be amended, corrected, or entered after
    rendering the service. When making review determinations the MACs, CERT,
    Recovery Auditors, and ZPICs shall consider all submitted entries that
    comply with the widely accepted Recordkeeping Principles described in
    section B below. The MACs, CERT, Recovery Auditors, and ZPICs shall NOT
    consider any entries that do not comply with the principles listed in
    section B below, even if such exclusion would lead to a claim denial. For
    example, they shall not consider undated or unsigned entries handwritten in
    the margin of a document. Instead, they shall exclude these entries from
    consideration.

    B. Recordkeeping Principles Regardless of whether a documentation
    submission originates from a paper record or an electronic health record,
    documents submitted to MACs, CERT, Recovery Auditors, and ZPICs containing
    amendments, corrections or addenda must:
    1. Clearly and permanently identify any amendment, correction or delayed
    entry as such, and
    2. Clearly indicate the date and author of any amendment, correction or
    delayed entry, and
    3. Clearly identify all original content, without deletion.

    ​Paper Medical Records: When correcting a paper medical record, these
    principles are generally accomplished by:
    1. Using a single line strike through so the original content is still
    readable, and
    *2. 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. Amendments or delayed entries to paper
    records may be initialed and dated if the medical record contains evidence
    associating the provider’s initials with their name. *

    Electronic Health Records (EHR): Medical record keeping within an EHR
    deserves special considerations; however, the principles specified above
    remain fundamental and necessary for document submission to MACs, CERT,
    Recovery Auditors, and ZPICs. Records sourced from electronic systems
    containing amendments, corrections or delayed entries must: a. Distinctly
    identify any amendment, correction or delayed entry, and b. Provide a
    reliable means to clearly identify the original content, the modified
    content, and the date and authorship of each modification of the record.

    *C. If the MACs, CERT or Recovery Auditors identify medical documentation
    with potentially fraudulent entries, the reviewers shall refer the cases to
    the ZPIC and may consider referring to the RO and State Agency.​*


    Daniel P. Clark, RN
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