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How to amend a signed chart note - katya


Posted: Mar 11, 2010

Gotta question - I work in-house for a group practice that oursources the transcription to a service, then I work as an editor for the final review before the paper copy goes for signature.  The paper copies are faxed to the cc list of doctors on that note.  The original is then scanned into an EMR, with the paper copy then shredded.  There is talk of an electronic signature, but we're not there yet.  So my question is this - what would be the best way to deal with a doctor's request to change something on a previous document that has already been signed, scanned, and faxed to the cc list, sometimes a week or more ago.  The change is not an MT error - example is, oops, I meant papilloma, not carcinoma, please change that in the diagnosis.

They are asking that we contact the service to make the change, put the word AMENDED at the top of the note, and then have it signed again, faxed again, etc., and we can delete it from the EMR and rescan it.  This doctor is new to this service (we have two), and is the only who is tending to want this kind of change.  Obviously, this sort of "error" should be caught before signed, but what if it's not?  Instead of AMENDED, would it be better to just dictate a separate note explaining the error of a previous note?  Or is the process they're asking for the best way to go?

Thanks for reading a lengthy question. 

I believe that legally you CANNOT replace a - SM

[ In Reply To ..]
new, corrected report for an old one already signed and in the chart. Where I work we typed an "addendum/correction" at the end of the original report, underneath the signature, and add whatever is being said, provided the one changing the report is the original signer of the report. If not, an entirely new report is created. Need to check with legal department for exact way to handle this. Something like this should already be in your policy/procedure manual.

Amend/Append/Addend - Ima MT

[ In Reply To ..]
You can't (or should not) alter or delete a signed electronic file. If there is an error, a new dictation has to be generated.

Whether you head the new dictation, AMEND/APPEND/ADDENDUM doesn't really make all that much difference, although AMEND would indicate it refers to changing a prior report.

Amending reports - workingmt

[ In Reply To ..]
I think it must be different at every facility. We have CMR with e-sig. If a provider wants to change a report after signing off on it, they dictate the change and we locate the report in the data base and change it, then it goes back to them again for review and sign off. I would say to follow your employer's guidelines.

The only problem with replacing a report already - SM

[ In Reply To ..]
in the chart is if that report has had copies sent to anyone, insurance, attorneys, other doctors etc., it can cuase a problem from a legal standpoint--especially with attorneys. That is why we do an addition/correction/addendum at the end of the report or generate a new report.
replacing report - clw
[ In Reply To ..]
The other problem with changing a finalized (signed) report is that care may have been given to the patient based on the erroneous information and that caretaker has no defense, unless your system does versioning.

Legally - Horski

[ In Reply To ..]
What our system does is adds an addendum to the bottom of a signed report which the provider then has to e-sign that too, and then it is reprinted anywhere it was printed before. If it is a typo and the date says 41 rather 14, many places fudge and unsign the document and make the change and the provider resigns, but I don't know how legal that is. If it is a change to the body of the report, it should be an addendum added to the bottom that is signed separately from the original document.

Changing a report - travelinMT

[ In Reply To ..]
Everyplace I have ever worked it has been illegal to change/ammend/append a report that has already been signed. Legally it is an issue if you change it after it has been signed and gone out. Electronic signatures automatically spit out copies and most systems it goes online to be viewable by anyone with the proper authority to view the patient's records. Changing the reports medicolegally can lead to huge legal problems and patient care problems. The original report has to be left intact and an appended report/addendum report has to be dictated, transcribed, signed and re-sent to everyone involved in receiving that patient's information.

Changing report - workingmt

[ In Reply To ..]
Interesting question and I learned some things from your answers. I really don't know what happens to the reports in the CMR after we correct them, I do know they go back to the provider for authentication a second time. It's all done electronically and I've never given it much thought. We used to do addenda manually and then resend them before they changed the system. I assume our clinic knows what they are doing medicolegally.


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