Know Difference Between Documentation Amendment and Addendum
Question: Why can’t a provider “unsign” a medical record, and then go back in and change it? Alaska Subscriber Answer: Data integrity is a crucial aspect of compliance, and compromising the data integrity of a medical record has myriad implications, including regulatory/compliance, financial, malpractice, audit, and continuity of care. “First and foremost, data integrity is about patient safety,” said Rhonda Buckholtz, CPC, CDEO, CPMA, CRC, CENTC, CGSC, COBGC, COPC, CPEDC, in her AAPC DOCUCON 2025 presentation “Mastering Documentation: Best Practices for Addendums and Amendments (DEEP DIVE).” “It’s about legal and regulatory compliance and, of course, reimbursement, auditing, and those types of things. But data integrity can lead to inaccurate or altered data, incorrect diagnoses, medication errors, or inappropriate treatments,” Buckholtz explained. Sometimes a provider needs to update or otherwise change a medical record, which is a legal document, and there are tools available to do so: amendments and addenda. An amendment is a correction or clarification to an existing entry, like when a provider closes a record and then realizes they should have added a detail. An amendment can be made at any time but must clearly indicate the date, the time, and the author of the change also, the original entry must be viewable, Buckholtz said. An addendum is new documentation that is added after the original entry to provide additional information that wasn’t available initially — a supplement or expansion to the original record. The addendum should be clearly identified as such, as well as dated and signed, she noted. Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC
