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Laterality not correct in EMR

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ortho1991

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North Andover, MA
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We are have a discussion in our office regarding laterality not being correct in chart note. Example provider documents in procedure note injection of LT knee when really the injection was RT knee and dx is for RT knee. Our question, is it ok to have the provider amend this note to reflect the correct side? It has always been my understanding that the provider can draw a line through the incorrect laterality LT and amend with the correct laterality RT. Also if this is ok to do is there a time frame as to when the documentation can be amended.
 
Old but valid: https://www.ahima.org/media/r2dc4xhg/amendments-in-the-electronic-health-record_axs.pdf
Not your MAC but info: https://med.noridianmedicare.com/we.../documentation-guidelines-for-amended-records https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00139902
Your MAC: https://www.ngsmedicare.com/web/ngs...leId=501581&lob=96664&state=97224&rgion=93623
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c03.pdf (Look here: 3.3.2.5 – Amendments, Corrections and Delayed Entries in Medical Documentation)

Does your practice not already have a policy for amendments and corrections to the medical record? If you have an EHR/EMR there should already be a process in place...
Please don't say you still use paper, handwritten charts. :oops:😬
 
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