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Electronic documentation tools offer many features that are designed to increase both the quality and the utility of clinical documentation, enhancing communication between all healthcare providers. These features address traditional...

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Backdating documentation medical

   24.02.2018  1 Comments

  • In addition to its clinical significance, the medical record is also...
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Physicians should exercise care in modifying or correcting medical records. Suggestions on when Backdating documentation medical how to go about that are provided. The medical archives contains valuable information about a patient's medical history and lone clinical interactions. Such information supports the ongoing care for the patient by the physician and other providers. In addition to its clinical significance, the medical record is also a rightful document that can Backdating documentation medical as evidence of the care provided.

A record correctly created at the time of the encounter and properly maintained contributes greatly to the prosperous defence of a lawsuit, or in responding adequately to a complaint to a regulatory hegemony College.

Generally, courts and Colleges have mandated that, among other things, medical records should be factually accurate and legible. Questions concerning whether a medical was contemporaneous or modified pile out from time to time in the course of proceedings in the presence of the courts and the Colleges. Backdating documentation medical review of these CMPA cases from — indicate that the most worn out issues arising from the modification of medical records were:.

The following two case studies picture important points to consider if you think it necessary to correct the medical record.

A year-old male truck driver presented to a walk-in clinic complaining of back pain after having fallen from his truck earlier that day. On physical test, there was tenderness of the lumbo-sacral spine, and limited across of motion in all directions. His neurological exam was regular. The physician prescribed analgesics and recommended follow up with the patient's own family physician and also a referral to a physiotherapist.


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Please contact customerservices lexology. I am sure that from time to time we have all come across the vexed question of backdating documents. Is it legal to comply with the request or must it always be refused outright? Alternatively, is there a way of legally trying to achieve the required objective?

For example, if a seller had sold his house Backdating documentation medical December then the seller could have taken advantage of certain tax benefits. However, he only realizes this in January and so wishes to backdate the document to December. The event did not happen during the time period required for the benefit so an attempt is being made to pretend that it did.

This is a fraud on the tax authorities, a criminal offence and is likely to get the lawyer who prepared the document disciplined by his regulator and possibly also charged as a co-conspirator. For obvious reasons, any request to backdate a document for these reasons should be flatly turned down.

However, an explanation often given by the person wanting to backdate the document is that the document is merely meant to reflect an oral agreement that has already been made and that this is just a way of documenting Backdating documentation medical. In theory, this would appear on the face of it to be a reasonable request, as it is just a private arrangement between two parties.

The argument is obviously not valid if the transaction is one which is required by law to be in writing such as a transfer Backdating documentation medical land. This is not an agreement that could have been made orally. However, even if it is an agreement that could have been made orally the lawyer preparing the agreement has no way of knowing whether that is Backdating documentation medical the case and that the agreement to be fully documented by him is the one that was reached at the earlier date.

He also has no way of knowing whether the backdating will be scrutinized by a regulatory authority or even a Court. Does he need to check to see whether that was actually the case or can he take an ostrich-like position and put his head in the sand and not ask any questions? What confirmation of the earlier agreement did the client or the company for which the client and lawyer works provide?

Is the client a longstanding one who has always acted properly in the past? How well does the lawyer know the client? These are questions he will probably be asked by the judge or regulator if things go wrong and to which he will need convincing answers.

Backdating documentation medical.

  • POOR OR EVEN NON-EXISTENT MEDICAL RECORD DOCUMENTATION IS NOT NECESSARILY AN INDICATOR OF FRAUD OR ABUSE. BACK-DATING IS MAJOR...
  • BACKDATING DOCUMENTATION MEDICAL
  • BACKDATING DOCUMENTATION MEDICAL

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Want to receive articles like this one in your inbox? Subscribe to CDI Strategies! Payers have been pushing back when a diagnosis appears in the discharge summary and not in the chart. Can the physician add a late entry or addendum into the medical record by way of a progress note or an addition to a discharge summary history and physical?

Can you help me Backdating documentation medical citations for this, as well? The American Health Information Management Association published practice guidelines that address late entries as follows:. Since our last edition, there have been significant changes to the rules and regulations Backdating documentation medical documentation in The only way to improve your clinical documentation improvement CDI program is to track the appropriate metrics and make During this live minute audio conference, our expert speakers will explain the benefits of outpatient CDI reviews During this live two-hour audio conference our speakers will provide tools to help you bridge the gap between clinical Policies for late entry documentation CDI StrategiesMay 27, Want to receive articles like this one in your inbox?

The American Health Information Management Association published practice guidelines that address late entries as follows: The "Backdating documentation medical" should clearly define how this process occurs within their system. Tracking and trending within the electronic record will be dependent on the system; the organization should clearly understand this process. The author should document within Backdating documentation medical entry that it is a late entry.

Dictated reports such as history and physicals, although dictated outside of organizational time frames, would not be considered a late entry. Some systems may not have late entry functionality. The late entry is shown as an addendum. When a pertinent entry was missed or not written in a timely manner, the author must meet the following requirements:. Contact her at fjurcak huronconsultinggroup. Implications of the Joint Commission's deletions for staff education and training requirements for HFAP revises ligature risks standards Healthcare organizations are addressing second-victim syndrome, but more must be done Fetal non-stress tests represent important part of maternal and fetal health Dig into the details of wound care documentation Coding Clinic reiterates guidelines for provider documentation Coding Clinic caveats CMS clarifies Method II CAH billing for anesthesiologist services Case Study: Backdating documentation medical.

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  • Please note that this article contains information that is only relevant to American clinics.
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