Documentation Guidelines for Amended Medical Records

April 17, 2017
Rick Gawenda

Have you ever wondered what constitutes an amended medical record? Have you ever wondered what constitutes a late entry, an addendum or a correction? Did you know that deliberately falsifying medical records is a felony offense? And lastly, do you know examples of falsifying medical records?

In this article, I will answer all the above questions. This is a must read for all therapists, therapist assistants, therapy assistants, office managers and compliance officers, just to name a few. To read the full article, log in or become a Gold Member now!

The content here is for members only log in here or sign up.

All material posted on our website is the intellectual property of Gawenda Seminars & Consulting, Inc. and can’t be used, reproduced, or posted as your own material without the prior written approval of Gawenda Seminars & Consulting, Inc.

This article is not intended to and does not serve as legal advice or as consultative services, but is for general information purposes only.

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.

  1. What is the process when a patient you have been treating for 2 separate conditions comes back and states that that one of these injuries is attributed to a separate incident. She now is requesting the second injury be billed under a second insurance? Is there a was now “split” the record so information can be provided to each insurance separately? Thank you!

    1. You would have 2 separate medical records for the 2 separate conditions being billed to 2 different insurance carriers.

  2. What is the best way to handle a situation you identify internally when reviewing a chart. Billing was entered for the date of service, but a note was never completed for that visit. This was recently identified 2 months after the visit date. Thank you.

    1. I would suggest you contact your healthcare attorney as due to liability reasons, I can’t address this question in this forum.