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    Categories: Health

5 Tips On How To Write An Addendum For A Medical Record

Treating a patient involves more than just a simple check-up at the doctor’s office. Nearly half of family physicians in the last year alone have been involved in some type of medical malpractice lawsuit.

After consultation with a patient, knowing how to write an addendum is key to avoiding any future legal repercussions. These 5 simple tips can help aid any health care professional in knowing how to write an addendum for a medical contract.

  1. Timely Corrections

Firstly, all staff will notify the original author of the contract before making any changes. Each state also contains a different time frame for allowing these changes. The best time for recording an addendum is during a questionnaire or shortly after each medical evaluation.

An addendum must include both the date and time of the correction. The original timestamp and the date of each revision should be included in each consecutive report.

  1. Local Policies

Each state has specific rules for amending changes, so be sure to verify which laws pertain to your state. The set of regulations should include:

  • Date and time of the revision
  • Name of physician or provider
  • Information changed
  • Reasons for alterations

Medical personnel must conduct audits to ensure that staff and providers are following proper procedures. Once you authenticate a record, make sure that the EHR can be tracked and corrected.

  1. Original Content

Avoid deleting any relevant information provided in the original report. Once a correction has been made, this record should be flagged to state alterations to the original document. All changes made to the record should be concise and accessible to future physicians and providers.

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  1. Give Detailed Reasoning

Give a detailed response about why an error is being corrected. Any further information should connect to the original report. For instance, shoulder pain may need clarification in the original report.

With that knowledge, a physician may add a proper addendum stating something such as:

“Patient complained of pain in the right shoulder and had trouble lifting his arm above his head. The pain is described as a 5 out 10.”

Make sure to strike out the original error before rewriting the correction. But, the error should not be completely obscured, this allows medical staff to use it as a cross-reference when reviewing the report. Feel free to search this post for further details on how to write an addendum to a contract.

  1. Signature Authorization

All documentation needs signatures by all parties before submission. This includes the physician providing the notes as well as the patient’s signature, along with any other required witnesses. The signatures need to be dated and legible to other healthcare providers.

How to Write an Addendum

With the evolution of medical bookkeeping, all medicare professionals must know how to write an addendum. It is important to educate your staff about the consequences of falsifying reports. If a medical professional fails to report these changes, it can result in a medical malpractice lawsuit.

Protect yourself and follow all guidelines for how to write an addendum to a contract. If you find this article useful, be sure to check out the health section of our blog!

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