The Medical Record is a Legal Document
Key Takeaways
Medical records are legal evidence. Accuracy and completeness decide your credibility, especially when a case lands in court years after the visit.
Never touch the original entry. Use a clearly labeled addendum or correction that’s dated, timed, signed, and states why you’re adding it. The doc includes clean examples for both.
Hygiene rules: every entry must be dated and signed; use timestamps for inpatient and any time-based services with start/stop times. Skip cloned notes, shared logins, and back-dating; keep access HIPAA-compliant with minimum-necessary and unique logins.
Medical records are considered legal documents, and their management is crucial for both healthcare delivery and legal accountability. Medical records are used to capture a patient's healthcare experience, including diagnoses, procedures, medications, treatment plans, and interactions with healthcare providers. These records are vital for patient care, and they have significant legal ramifications.
In our current environment of electronic records there are multiple concerns for data integrity, and inappropriate documentation resulting from poorly designed templates, notes cloned forward and lack of an audit trail. Lack of an audit trail can result in unauthorized edits, deletion of entries and/or overwriting original entries. Shared logins must not exist and yet providers are found asking staff to go in under their login to make “corrections”. Back dating notes represents an activity that violates medical record compliance standards. Stick to the FACTS, do not embellish or offer unrelated personal commentary.
Medical records must adhere to privacy and security regulations, such as the Health Insurance Portability and Accountability Act (HIPAA), which governs the handling of protected health information (PHI). This also limits access to minimum data exposure needed to perform duties, separate logins and secure storage of records.
All entries into the medical record must be dated and signed. A time stamp is recommended if you are providing care in the inpatient setting (especially where multiple providers are engaged in care of the same patient) and/or if you are billing based on time per updated criteria for assigning a level of evaluation and management services. Time based services such as physical therapy will also require documentation of a start and stop time.
When changes to the medical record are needed the original entry must not be changed. An addendum or correction / amendment must be entered separately and timed/dated and signed by the provider. The amendment or addendum must be labeled as such and the reason for the additional entry must be cited. Below is a clinical example of a compliant Addendum.
Clinical Example - Addendum
A 45 year old woman comes to clinic and sees Dr. Jones with complaints of fatigue and bruising on September 1, 2025, and the provider ordered a CBC with differential. The results return with a low RBC, Hct, and Hgb. Dr. Jones calls the patient on September 3rd to discuss the test results and the diagnoses of anemia. She sends an order to the pharmacy for an iron supplement and orders a follow up CBC in 2 weeks.
Dr. Jones makes the following entry into the medical record-
Addendum – 09/03/2025 1505 -1515 Telephone visit with <patient name> to discuss new CBC results with low values for RBC, Hct and Hgb. Discussed a need for an iron supplement and a prescription was sent to Walgreens. She indicated a good understanding of her lab study and the treatment plan for Iron supplements and a recheck in 2 weeks. Signed Dr. Jones 09/03/2025 1525
Clinical Example - Correction to the Medical Record
08/05/2025 - Mr. <_______> was seen for a chief complaint of lower pelvic pain and he indicated his last menstrual cycle was in August 2025. He indicated that he had a spicy Indian meal and he suffered indigestion, nausea and diarrhea and has had persistent lower pelvic pain.
Dr. Smith
Correction
08/05/2025 - Mr. <_______> was seen for a chief complaint of lower pelvic pain and he indicated his last menstrual cycle was in August 2025 Error KJS 09/01/2025. He indicated that he had a spicy Indian meal and he suffered indigestion, nausea and diarrhea and has had persistent lower pelvic pain.
Dr. K. J. Smith
09/01/2025 0830 Please see strike through above this error was a result of unwanted template input. Dr. KJ Smith
Medical records are used as evidence in court to establish facts related to personal injury cases, medical malpractice claims, and disability claims. They can demonstrate the standard of care provided and the extent of injuries sustained. The accuracy and completeness of medical records is paramount! Discrepancies in the medical record can significantly impact legal outcomes.
An additional key consideration is the fact that a legal case may not arrive to trial for years after the events occurred. The clinical record is the clinician’s lifeline to being able to offer an intelligent and defensible testimony years after the fact. If it is inaccurate, incomplete or tampered with the provider or institution may not have a leg to stand on.
Documenting in the clinical record may be akin to having teeth pulled without the benefit of anesthesia for some providers, but it is their bread and butter, medical malpractice defense, audit to billing defense and it provides continuity of care between visits and providers. The spotlight on this activity has burned brighter over the past 25 years but the need for clinical documentation has always been there.
ELEVATE MEDICAL SOLUTIONS: YOUR TRUSTED PARTNER MEDICAL CODING
At Elevate, we’re dedicated to helping medical coders like you excel. Stay ahead of the curve by subscribing to our blog for the latest resources, industry insights, and exclusive webinars where you can earn AHIMA-approved CEUs—all for free.
Join Our Community Today!