The rules to modifying the Patient Record should be strong foundation for the enterprise seeking to develop policies and procedures. In order to ensure the admissibility of the medical record as evidence, the enterprise must first establish policies and procedures that address

• Author authentication
• Medical record access control
• Medical record archiving and retention
• Medical record security
• Medical record disaster recovery policies and procedures

By establishing controls over the creation of medical records, enterprises can ensure the nonrepudiation of corrections, revisions, additions, and addenda made in the normal course of business.

Ultimately, by controlling the how, who, where, and when of creating the medical record, the enterprise establishes the methodology for performing valid corrections, revisions, additions, and addenda.

The best practices of a healthcare enterprise can develop an effective and valid policy and procedure for the correction, revision, addition, and addenda of health information contained within the medical record.

The key characteristics of an effective policy and procedure include

• Author authentication and accountability
• Clear indication of correction or amendment date and time
• Policies and procedures that prevent unauthorized alteration of documents
• Clear delineation of parent document
• Clear delineation of corrected or amended document
• Notification of health information recipients when amendments and corrections occur
• Retention of the parent document for historical reference

Though it is true that no single rule that addresses medical record correction and amendment exists, enough guidance is available to allow healthcare providers to develop a workable policy and procedure to address the creation of valid medical record corrections and amendments.