Add a dated addendum that you sign and the doctor co-signs. Notes in the medical record are permanent and cannot be altered. An addendum is a new, later entry. It can correct or add to anything written before. It carries the date and the signature of its author. The doctor then co-signs to show the entry is valid. The first note stays exactly as it was.
The chart is a legal document. Your notes also support the bill sent to Medicare or an insurance company. So the record must show what was done and when it was done. A signed electronic note cannot be deleted. It can only be amended. Quietly retyping the old note hides the change and the date, which is the very thing an audit looks for. On paper the rule matches: draw a single line through the wrong item, then date and initial it. Never use white-out and never erase. An audit asks one simple question. What did the chart say on the day of the visit? An addendum answers that question honestly. It shows the first note, the new fact, and the day the new fact was added.
Carry one rule into the exam room. Never hide a change; add to the record instead, and sign and date what you add. Write the addendum as soon as you spot the gap. Say plainly what was missing and where the number came from. Handling charts this way protects the patient and the practice, and it sits at the heart of the COA history and documentation content area.
Incorrect Answers
- A. A completed, signed note in an electronic record cannot be deleted. It can only be amended, so this choice is not even possible in a proper system. Deleting a note also destroys proof of the care that was given.
- C. Editing the words of a signed note alters a permanent entry. The new number would look as if it had been there all along. That silent kind of change is what an auditor treats as fraud.
- D. A loose worksheet is not part of the signed note. The reading would sit outside the record that the doctor and the biller read. Loose paper is also easy to lose or misfile.
Testing Pearls
- Entries in the medical record are permanent; add an addendum instead of changing them.
- An addendum is dated and signed by its author, and the doctor co-signs it.
- A signed electronic note can be amended but never deleted.
- On paper, draw a single line through an error; white-out is not allowed.
- Scribing means recording the doctor's exact words, not a summary.
References
- American Academy of Ophthalmology. Ophthalmic Medical Assisting: An Independent Study Course. Chapter 19, Understanding Practice Management.
