Risk Management Series 1- Documentation in Allied Health

Tip #4: Is an Addendum or Correction OK?

The short answer is, yes, an addendum or correction is ok, and actually is needed to clarify the care or to correct misinformation.  It must be clear, however, that your addition to your previous note is an addendum or correction.  Avoid an addendum or correction that may appear self-serving or is not substantive.  Never erase or destroy the original note in a record.  If using an EMR, your initial documentation may still appear in the record in crossed out form, so any third party reading the record can still see the original documentation as well as the addendum or correction.  Always note the reason for the addendum or correction and the date it was made (if not using an EMR). 

Be sure to check your profession’s ethical guidelines on documentation principles.  When you have questions, it is best to consult an attorney for guidance.

 

 

Kristen Lambert, JD, MSW, LICSW, CPHRM, FASHRM
Healthcare Practice and Risk Management Innovation Officer
Trust Risk Management Services, Inc.
email: contact@trustrms.com

 

NOTE: This information is provided as a risk management resource and is not legal advice or an individualized personal consultation. At the time this resource was prepared, all information was as current and accurate as possible; however, regulations, laws, or prevailing professional practice standards may have changed since the posting or recording of this resource. Accordingly, it is your responsibility to confirm whether regulatory or legal issues that are relevant to you have since been updated and/or to consult with your professional advisors or legal counsel for timely guidance specific to your situation. As with all professional use of material, please explicitly cite The Trust Companies as the source if you reproduce or distribute any portion of these resources. Reproduction or distribution of this resource without the express written permission of The Trust Companies is strictly prohibited.

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NOTE: This information is provided as a risk management resource and is not legal advice or an individualized personal consultation. At the time this resource was prepared, all information was as current and accurate as possible; however, regulations, laws, or prevailing professional practice standards may have changed since the posting or recording of this resource. Accordingly, it is your responsibility to confirm whether regulatory or legal issues that are relevant to you have since been updated and/or to consult with your professional advisors or legal counsel for timely guidance specific to your situation. As with all professional use of material, please explicitly cite The Trust Companies as the source if you reproduce or distribute any portion of these resources. Reproduction or distribution of this resource without the express written permission of The Trust Companies is strictly prohibited.