Documentation addendum

[BIANCA04]

There seems to be some confusion...if some info was missed on the initial documentation what is the appropriate way to add. I requested an addendum be added to the pts record. Instead the same note was used and the "missed" info was added to the new note in the spot it should have originally been placed.
Suggestions?

Thank you

 

[mhstrauss]

There seems to be some confusion...if some info was missed on the initial documentation what is the appropriate way to add. I requested an addendum be added to the pts record. Instead the same note was used and the "missed" info was added to the new note in the spot it should have originally been placed.
Suggestions?

Thank you

You are correct in that this should have been done as an addemdum, which should include the date of the addendum, brief explanation, and signature of the person doing the addendum. The way you described above is certainly considered fraudulent.

 

[FTessaBartels]

It depends

There are many ways to correct documentation and some depend on the format of the original documentation and whether it is still in "draft" mode or not.

For example
A handwritten hospital admission note that has been signed & dated by the provider, but is missing any assessment/plan. You query physician; s/he should go back to the the original document ... if there is ROOM on the page, the information can be added right there BUT the provider must initial/sign and date the added material.

If it is a dictation and you catch that there is missing information before it has been finalized/signed, the provider can edit the document to include the missing info and just sign it.

Hope I am making myself clear.

The key is that this is a legitimate correction/addendum to reflect what actually occurred, but which may not have been correctly documented.

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[dpumford]

Monitor/attestation

Hi: If there is a physician monitoring a physician and it is listed as such; and the assst is a CRNFA, which we would not bill for, Am I correct to say the we do not bill for the monior?

He is using his valuable time but yet he is just monitoring.

Also If a resident dictates and Initial Evaluation & Management, there is no attestation by the surgeon, but the resident state he spoke with Dr. G and he agreed. Is it OK to have the surgeon do a amendment and add the attestation to the report even if its a month old?

This in advance!!!