Revising Clinical Record Documentation

Title: Revising Clinical Record Documentation
Standard #:


Issued: 12/01/1997 Reviewed/Revision Date:  08/21/2000


If a provider needs to revise, amend, or correct any previously completed documentation, the following procedures will apply:


If a provider needs to delete any material, the provider may do so by drawing a line through it in such a way that the underlying notes can still be read.  The provider must sign and date the deletion with the date the deletion was made.

If a provider replaces any deleted notes, or adds new notes, the provider may do so by documenting these in the patient record on the day on which he/she is the changing or adding new notes.  The provider must date and sign those notes on the day on which he/she is writing the notes and should cross-reference these notes to the date upon which the patient care was actually rendered.  The provider may not “black out” or remove the notes on the day when they were originally written, nor write new or amended notes into the record on that earlier date.

Once hospital administration determines that an inpatient chart has been completed, subsequent modifications may be made in accordance with hospital policy and the above rule for clinical purposes only, but not to remedy documentation deficiencies for billing purposes.  Likewise, outpatient records may not be changed for billing purposes once the initial documentation has been entered into the medical records.