A few weeks back, we featured a 12-part blog series on documentation. One segment, Tip #4, asked the question, “Is an Addendum or Correction OK?” This Tip seemed to spark a lot of interest, so we thought it would be good to expand on this issue a bit more.
There are times when we come across typos, errors, or mistakes in written publications or products. What do you do, however, when an issue occurs in your documentation; e.g., you become aware of an error or feel you need to correct your documentation in some way? How do you determine when to leave a minor error alone or correct the record? This can be a tricky issue both in documentation in an Electronic Medical Record (EMR) and in written format.
As indicated previously, it may be important to correct your record, whereas it may not be necessary in other circumstances. When I previously practiced as a defense attorney, I encountered addendums or corrections in the record. I have also seen addendums or corrections become a central issue in a lawsuit and on occasion where a provider’s addendum affected the case so much that the matter needed to be settled.
This is a not a clear-cut issue. Each case is different, and the decision to create an addendum or correction depends upon the needed correction itself, the provider, and the circumstances of the treatment. At times, addendums or corrections are wholly appropriate and necessary. For example, an Allied Health Professional (AHP) intended to document, “The patient did not comply with treatment” but instead typed, “The patient did comply with treatment.” Another example, “The patient indicated she is taking Paxil 500 mg once per day as prescribed by her PCP.” Instead he/she meant to document, “The patient indicated she is taking Paxil 50 mg once per day as prescribed by her PCP.” The impact of the error in both these examples changes entirely, and it would seem important to document an addendum or correction.
However, there are times where an addendum or correction may not be indicated. For example, an AHP typically documents a note of an approximate length for each encounter. An adverse issue occurs, and following the incident, the AHP reviews his/her note in the EMR and decides to expand on the note through an addendum. The AHP recreates a note appropriately three times the length of his/her typical documentation practice. Given the circumstances, he/she thinks explaining the rationale for a decision would be best in the record. The note does not appear similar in length or what the AHP typically documents with patient encounters. The original note remains in the medical record but appears crossed out in the addendum. In this case, any third party reviewing the patient’s medical record would compare the two notes to identify differences. In the context of litigation, the AHP’s note and typical practice may be explored in the legal arena and could result in negative consequences, including lack of credibility. The AHP may be asked about the addendum or correction, why it was done, and is it typical in his/her practice. Further, standards of practice may also be examined.
Ultimately, it is not a straightforward answer of whether or not to insert a correction or addendum. It is case specific. Here are a few tips to keep in mind. Prior to documenting an addendum or correction, be sure to:
- Determine if it is necessary to clarify the care or correct misinformation.
- Ensure you that your subsequent note is labeled an addendum or correction.
- Examine whether it is self-serving, or if the addendum or correction is substantive.
- Do not erase or destroy the original note in a record.
- Document the reason for the addendum or correction.
- Document the date the addendum or correction was authored.
- Be aware if your profession has guidance on documentation, specifically addendums or corrections. Consider reviewing ethical guidelines before they are needed.
- Determine if you need to consult with your supervisor or if there is an internal process within your organization prior to creating an addendum or correction.
- Determine whether you should consult with a risk management professional or attorney to obtain advice.
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Kristen Lambert, JD, MSW, LICSW, CPHRM, FASHRM
Healthcare Practice and Risk Management Innovation Officer
Trust Risk Management Services, Inc.
email: contact@trustrms.com
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