Confidentiality, Privacy and Security

Correction of clinical documentation

  • 1.  Correction of clinical documentation

    Posted 06-18-2019 13:49
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    We are having discussions regarding the timeliness of corrections within the electronic health record. CMS states clinical documentation should be completed at the time of service. CoP indicates documentation for a service should be completed within 30 days following the service or less depending upon facility bylaws and/or policies. My question is related to corrections to existing documentation and if there are time limitations to these corrections. A law office our facility works with has recently stated that there should be no corrections or changes to the electronic health record after the 30 day time period has passed. I am trying to corroborate this statement, or locate regulations/guidelines that state the accuracy of the medical record should be maintained regardless of time limits. Any assistance would be appreciated. Thank you
    Vicki Dunn,RHIT,CHPS,CCS-P,MPA
    Him Director
    Mary Greeley Medical Center
    dunn@mgmc.com



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    Vicki Dunn,RHIT,CHPS,CCS-P,MPA
    Him Director
    Mary Greeley Medical Center
    dunn@mgmc.com
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  • 2.  RE: Correction of clinical documentation

    Posted 06-19-2019 17:33
    Please request the patient to sign a copy of the authorization form before a notary public also you can request a notarized copy of the patient ID card✌️

    VICTOR N. MOTURI MBA, RHIA
    Health Information Consultancy




  • 3.  RE: Correction of clinical documentation

    Posted 06-20-2019 14:19
    Under HIPAA, a patient has the right to request a correction be made to their record regardless of how long it has been.  You can read more about it here:  https://www.hhs.gov/hipaa/for-individuals/medical-records/index.html

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    Jesse Floyd, RHIA
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