Performance Measurement Network

Question: Can an addendum be added to the medical record?

This is follow up to a prior question: "Stroke VTE Prophylaxis ";.

MD documented in progress notes that pt. was ambulatory on day 1 and 2. No further information documented re: VTE prophylaxis. Is it acceptable for the MD to dictate an addendum to the record stating the reason for no prophylaxis then reabstracting the record with the additional information?

Answer:

The intent of abstraction is to use only documentation that was part of the medical record during the hospitalization (is present upon discharge) and that is present at the time of abstraction. There are instances where an addendum or late entry is added after discharge. This late entry or addendum can be used, for abstraction purposes, as long as it has been added within 30 days of discharge, [Refer to the Medicare Conditions of Participation for Medical Records, 42CFR482.24©(2)(viii)], unless otherwise specified in the data element. It is not the intent to have documentation added at the time of abstraction to ensure the passing of a measure.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: STK-01,
File:

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