People screw up. We are human; hence the term, “human error.”

But how to handle said mistakes in health care records after the fact, which could be the target in a Medicare/caid audit?

This is a very important, yet extremely “fine-lined” topic. Imagine a tightrope walker. If you fall off one way, you fall to the abyss of accusations of fraud. You fall off the other way and you fall into the ocean of the False Claims Act. Fixing document errors post date of service (DOS) is a fine line with catastrophic consequences on both sides.

In NC, our administrative code provides guidance.

“SECTION .1400 – SERVICE RECORDS
10A NCAC 13J .1401 REQUIREMENT

(a) The agency shall develop and implement written policies governing content and handling of client records.

(b) The agency shall maintain a client record for each client. Each page of the client record shall have the client’s name. All entries in the record shall reflect the actual date of entry. When agency staff make additional, late, or out of sequence entries into the client record, the documentation shall include the following applicable notations: addendum, late entry, or entry out of sequence, and the date of the entry. A system for maintaining originals and copies shall be described in the agency policies and procedures.

(c) The agency shall assure that originals of client records are kept confidential and secure on the licensed premises unless in accordance with Rule .0905 of this Subchapter, or subpoenaed by a court of legal jurisdiction, or to conduct an evaluation as required in Rule .1004 of this Subchapter.

(d) If a record is removed to conduct an evaluation, the record shall be returned to the agency premises within five working days. The agency shall maintain a sign out log that includes to whom the record was released, client’s name and date removed. Only authorized staff or other persons authorized by law may remove the record for these purposes.

(e) A copy of the client record for each client must be readily available to the appropriate health professional(s) providing services or managing the delivery of such services.

(f) Client records shall be retained for a period of not less than five years from the date of the most recent discharge of the client, unless the client is a minor in which case the record must be retained until three years after the client’s 18th birthday. When an agency ceases operation, the Department shall be notified in writing where the records will be stored for the required retention period.”

What NOT to do:

• Erase notations and write the revision
• Add a check mark that was not previously there
• Forge a staff’s initials
• Back date the revision

When it comes to alteration of medical records for Medicare/caid patients after the DOS, you are walking on a tightrope. Catastrophe is below, not a net. So tiptoe carefully.

Call an attorney with specific questions.