Accurate, complete, and timely documentation is essential in health care. It not only provides a comprehensive picture of the patient’s encounter, it’s essential to support payment, medical necessity, and compliance with relevant laws and regulations, like the False Claims Act.
When information is erroneously omitted from a note, an error occurs, a change or clarification is needed, or additional documentation is needed to supplement a previous entry. When these situations occur, use this tip sheet on how to aid in the correct workflow for documenting late entries and addendums to clinical documentation.
If you have questions or need to report deliberate falsification of documentation, please contact Corporate Integrity.