Modifying a signed note

Maintaining accurate and compliant clinical records relies on the integrity of signed documentation. As a result, changes to signed notes in the EHR are restricted. However, properly administered amendments are permitted via addendums. This article covers guidelines for modifying signed clinical documentation.

Signed Notes Cannot Be Edited

Once a clinical note is digitally signed in the patient record, it cannot be deleted or directly edited. The original signed entry must remain unchanged. This preserves an auditable documentation trail.

Addendums Allow Clarifications

While signed notes themselves remain static, providers can append clarifying addendums. These may be used to:

  • Add relevant updates if new information emerges
  • Address and resolve conflicting documentation
  • Correct minor documentation errors

Proper Addendum Procedures

Note: If you are a therapist participating in the Beta for clinical documentation in the Rula provider portal, see [Beta] Adding an addendum to a signed note in the Rula provider portal

When needing to modify a signed clinical note in the EHR:

  1. Locate the patient's chart
  2. Find the session in the timeline
  3. Select the "..." menu to access options
  4. Choose "Add Linked"
  5. Pick "Patient Note" to append addendum
  6. Then select "8 – Blank Note" as the note template.
  7. In the Patient Note, document the current date and time. 
  8. Write "addendum" or "clarification" at the start of your note as the purpose.  
  9. State the reason for the addendum or clarification referring back to the original entry 
  10. Write the addendum or clarification.  

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The addendum should then:

  • Be dated/timed after the original note
  • Reference the outdated/conflicting information
  • Provide the updated details or corrections

Example of an addendum: 

"ADDENDUM: This is an addendum to the Progress Note dated November 17, 2022, to provide additional collateral information the client's mother provided after the session. The client's mother reports the client missed school last week due to experiencing a panic attack while at the bus stop." 

 

Example of a clarification: 

"CLARIFICATION: This is a clarification to the Initial Assessment dated November 10, 2022, to correct an error in documentation regarding the client's employment status. The client reports he is employed part-time." 

 

Example of an error: 

"ADDENDUM:  Progress note dated November 10, 2022, was entered incorrectly in the wrong client's chart. Please disregard this note, which should not be part of this client's medical record." 

  • Sign the Patient's Note

Note: Do not generate a new charge slip for a supplement or clarification.

 

Additional Resources

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