Jessica, PT, DPT, (age 26) has been practicing in an established outpatient private practice for 6 months. The practice has outgrown its current space, so the clinic recently moved to a larger location. With all of the extra duties involved in relocating the practice, Jessica and many of the other PTs fell behind on their documentation. After all, they have so many new patients with Medicare being referred to them because their new location is so close to the hospital. Some unsettling news is shared with the PTs. The practice owner was just informed by a Medicare contractor that her practice is scheduled to be audited. The owner, who knows the PTs are all behind on their documentation, instructs everyone to "spend the next few days creating notes for the patients' records from memory and date the documentation to reflect the date patients were actually treated so nothing is amiss during the audit." It's hard for Jessica to remember all of the details of each patient's therapy sessions. Jessica does her best to complete the documentation as accurately as possible.
Jessica is confronted by a problem. She is not sure she documented accurately from memory and is concerned she did not date her notes appropriately. For certain patients, she documented interventions without knowing whether they were in fact provided during the session. Preferably documentation should have been completed at the time care was delivered or at a minimum on the same day as the care was given. Additionally, adding documentation to a patient's record after the fact is only permitted when the additional note is shown in the record as a late addition and the date of the late addition or addendum includes the date it was written and included in the record. Jessica's actions, whether she knew it or not, could be considered fraud and abuse by the government.
Never back date. It's perfectly legal to make corrections or amendments to medical records, but they need to include the date of the revision.
Jessica needs to admit to her supervisor that she can't remember certain details. She also should refer to the CMS Manual System for guidance on making amendments, corrections, and delayed entries in medical records.
Last Updated: 9/10/2014