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. Show
When making review determinations the MACs, CERT (Comprehensive Error Rate Testing), Recovery Auditors (RAC), SMRC, and UPICs shall consider all submitted entries that comply with the widely accepted Recordkeeping Principles described below. The MACs, CERT, Recovery Auditors, SMRC, and UPICs shall NOT consider any entries that do not comply with these principles, 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. 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, SMRC, and UPICs containing amendments, corrections or addenda must:
Paper Medical Record
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, SMRC, and UPICs. DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts. What is the acceptable time frame for delayed entries into a patient's medical record?Delayed entries within a reasonable time frame (24 to 48 hours) are acceptable for purposes of clarification, error correction, the addition of information not initially available, and if certain unusual circumstances prevented the generation of the note at the time of service.”
What is the proper way to make a correction to an entry on a paper health record?When an error is made in a medical record entry, proper error correction procedures must be followed.. Draw line through entry (thin pen line). ... . Initial and date the entry.. State the reason for the error (i.e. in the margin or above the note if room).. Document the correct information.. What are 3 things you should not add to a medical record?The following is a list of items you should not include in the medical entry:. Financial or health insurance information,. Subjective opinions,. Speculations,. Blame of others or self-doubt,. Legal information such as narratives provided to your professional liability carrier or correspondence with your defense attorney,. What are 3 things in a medical record?An electronic health record (EHR) contains patient health information, such as:. Administrative and billing data.. Patient demographics.. Progress notes.. Vital signs.. Medical histories.. Diagnoses.. Medications.. Immunization dates.. |
