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Question: If a healthcare practitioner makes an addendum to a patient鈥檚 medical record, does the addendum require a signature?

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Answer: Yes, according to Noridian, a Medicare Administrative Contractor (MAC).

Noridian defines addendum, saying 鈥淎n addendum is used to provide information that was not available at the time of the original entry. The addendum should also be timely and bear the current date and reason for the addition or clarification of information being added to the medical record and be signed by the person making the addendum鈥� (emphasis original).

Noridian cautions that anyone making changes to a physical medical record, even to make addenda that are serving as corrections, should not 鈥渨rite over or otherwise obliterate鈥� the passage or entry to the medical record. As for electronic records, the same principles apply.

鈥淐orrection of electronic records should follow the same principles of tracking both the original entry and the correction with the current date, time, reason for the change and initials of person making the correction. When a hard copy is generated from an electronic record, both records must show the correction. Any corrected record submitted must make clear the specific change made, the date of the change, and the identity of the person making that entry,鈥� Noridian says (emphasis original).