Page 35 - Risk Reduction Series - Documentation Essentials (Part One)

SVMIC Risk Reduction Series: Documentation Essentials

Unclear documentation of an addendum or amendment to the

medical record is a challenge to the defense. An addendum is
intended to record information not available when the original

entry was made. It should include the date of the addendum and
an explanation about why the entry is needed.

An amendment is used to correct an erroneous entry and may

also be requested by a patient. Under HIPAA, a covered entity
must permit an individual to request an amendment and provide

a reason to support a requested amendment but may deny the
request. For example, a patient may request a positive drug

screening test be removed from the record, but the physician
denies the request as it is not inaccurate and should remain

part of the medical record. If an amendment is granted, for
example, the record states patient had hysterectomy when she

did not, then the documentation should include the date of
the amendment and a brief explanation about why the patient

requested it. SVMIC is here to assist with patient requests for
amending the medical record and encourages policyholders to

speak with a claims attorney before amending a record.

Changes in the medical record, including additional notes,

after receipt of a claim or lawsuit should not be made without
consulting an SVMIC claims attorney. Alteration of the medical

record could trigger an allegation of spoliation. The theory of
spoliation of evidence refers to an intentional destruction of

evidence for the purpose of depriving opposing parties of its
use. Spoliation may subject you to professional discipline, may
5
be used as a separate grounds for a claim independent of any
alleged malpractice, and may even result in criminal charges.

5 Desselle v. Jefferson Parish Hosp. Dist. No. 2, 887 So. 2d 524, 534 (La. App. 5th Cir. 2004)

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