April 2001 Bulletin

Correcting a medical record is possible

Establishing procedures and following them carefully can protect you from liability

By Carolyn Rogers

One key, but often overlooked aspect of practice management is establishing a system for correcting practice records. Why is this so important?

"If it’s done wrong, it creates very bad inferences that can be catastrophic in a court room," says Dan Tennenhouse, MD, JD, a lecturer in legal medicine at the University of California School of Medicine and a medical-legal consultant. "There are many people in an office who could potentially make those mistakes, so you need to have a policy in place that covers everybody."

Establishing proper procedures for correcting practice records—from medical charts to phone messages and employment files—could protect you from needless liability as well as help your relationships with managed care payers, Dr. Tennenhouse says.

In court or in an audit, if a document is missing or gives the appearance of being improperly altered, it will generally be construed against you. Managed care and liability insurers are also becoming more particular about the ways in which record corrections are handled. "It’s a quality assurance and liability issue," Dr. Tennenhouse explains.

Implementing a records correction program requires setting up policies and procedures and training staff in their content and use. Supervisors should be trained in the importance of proper correction procedures for all practice records, and instructed to enforce the policies. The following are standards for correction policies and procedures.

Adopt and periodically review a policy on when to correct records. It should cover the following points:

Develop and, from time to time, review procedures for correcting practice records. They should include the following:

Make and, from time to time, revisit a policy on destroying and/or rewriting records. It should include the following:

In the event of a lawsuit, if these procedures haven’t been followed, your record-keeping practices can be questioned and the value of all of your records for the defense of your lawsuit can be questioned, Tennenhouse says.

"Unfortunately, physicians often feel they don’t have the time to continually orient all of their staff to proper record-keeping practices," Dr. Tennenhouse admits. "And as a result, individuals will make mistakes on a regular basis. You just hope nobody makes a mistake with a record where there is a potential for litigation."

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