What Are The Ethical, Legal & Clinical Considerations For
Altering or Correcting Clinical Records?
Clinical Update June 2016
By Zur Institute
We keep records for several reasons:
- Good record keeping helps clinicians organize the treatment plan.
- Good records of treatment help to maintaincontinuity of care when clients shift to new therapists.
- Good records can protect clinicians in cases of board investigations, lawsuits, etc.
- They help in the event of the therapist’s sudden disability, death, etc.
- Keeping records is a mandated part of the standard of care.
Valid reasons to consider correcting records include:
- When there is an incorrect notation regarding diagnosis, CPT code, prognosis, intervention, client’s behavior, motivation, plans, etc.
- Accidentally writing a wrong word or terms in the notes
- A client makes a valid, reasonable, and justifiable request to amend or correct the records
Accurate records are very important:
- Records inform subsequent therapists and are critical for determining a continued course of treatment
- Records can determine a client’s eligibility for disability, retirement, keeping a job, maintaining custody of a child, security clearance, capacity to stand trial, etc.
- Inaccurate or wrong records can be costly, particularly in litigation, for clients, therapists, or other people involved
Altering records (Don’t):
- Some therapists attempt to alter records after they receive a subpoena.
- Altering DX or CPT codes so clients will be eligible for insurance reimbursement is unethical.
- Erasing, deleting, removing, re-writing, whiting-out, and similar ways of ‘altering’ records, where the original records are no longer visible or adding content at a later date without indicating that changes took place are NOT acceptable and can be easily seen as an attempt to distort, conceal, commit fraud or mislead.
- Note that forensic experts may be able to detect altered hand-written or typed-up clinical notes or EHR which have been tampered with.
- Altering records is unethical and below the standard of care.
- In summary, DO NOT ALTER records.
- Generally, ways of changing or correcting records are neither specified in law or regulation, nor in the codes of ethics.
- Transparency seems to be a key issue.
- While HIPAA gives clients the right to review their records and request corrections, it does not specify how these corrections should be made (assuming the therapist agrees to make the requested changes).
- Reasonable ways to correct records include:
- If strikethrough is used, it should be made to the language to be changed, where the strikethrough original text is still readable.
- Do not erase or blacken the original entry. Make sure the original entry is still readable.
- Document the date, time and reason for the correction or amendment of the records.
- If appropriate, explain the reason for the correction, i.e., write in the notes, something iike “Mistaken entry”.
- Treat typed-up records as handwritten records: Indicate the date, time, reason and who initiates the change.
- Correct EHR with full transparency (when, what, why, etc.).
- When in doubt, consult!