Correcting a Medical Record: The Only CoP-Compliant Method for Small Practices (42 CFR § 482.24(b)(4))

Medical records are the backbone of patient care and compliance. For small practices, the accuracy and integrity of these records are critical not only for delivering safe treatment, but also for surviving Medicare Conditions of Participation (CoP) audits. Under 42 CFR § 482.24(b)(4), providers are required to maintain medical records that are accurate, authenticated, and unaltered.

But mistakes happen. Physicians may record an incorrect dosage, nurses might mis-document the time of medication administration, or clerical staff may enter patient demographics incorrectly. When errors occur, practices must know how to correct medical records properly without violating CoP standards.

This article provides a compliance guide for small practices on correcting medical records. It explains the regulatory requirements, highlights common pitfalls, and offers step-by-step methods, checklists, and best practices for ensuring corrections are legally compliant, transparent, and defensible during audits.

Understanding 42 CFR § 482.24(b)(4)

The regulation requires medical records to:

• Be accurate, complete, and promptly filed (42 CFR § 482.24(b)).

• Retain the original entry, even if it is incorrect.

• Include any corrections or amendments with proper authentication.

• Show the date, time, and identity of the person making the correction.

Importantly, records may not be erased, deleted, or obscured. Instead, corrections must preserve the original information while clearly documenting the change.

Why Proper Corrections Matter

1. Regulatory Compliance

• CMS surveyors focus heavily on record integrity during audits. Improper corrections can trigger deficiency citations.

2. Legal Defense

• Courts and malpractice attorneys scrutinize medical records. Altered records raise red flags and undermine defense credibility.

3. Continuity of Care

• Future providers need to see both the original error and the corrected entry to understand clinical decisions.

4. Patient Trust

• Transparent corrections reassure patients that providers handle errors responsibly.

Errors should be corrected as soon as they are discovered. Delays can appear as attempts to conceal mistakes. Staff should be trained to:

• Recognize errors immediately.

• Report them to supervisors or compliance officers.

• Begin the correction process promptly.

For practices still using paper records, corrections must follow a strict process:

1. Draw a single line through the error, so the original text is still legible.

2. Write the correct information nearby (above, below, or next to the error).

3. Initial and date the correction.

4. Include an explanation if needed (e.g., “incorrect dosage recorded”).

Prohibited actions (42 CFR § 482.24(b)(4)): 

• Erasing the entry.

• Using correction fluid (“white-out”).

• Scribbling out the entry so it is illegible.

Electronic Health Records (EHRs) must maintain a permanent audit trail. Corrections are handled by:

• Adding an addendum noting the correction.

• Entering the corrected information in a new field.

• Avoiding overwrites of original entries.

• Authenticating with electronic credentials (unique username and password).

Audit trails must capture:

• The original entry.

• The correction made.

• The identity of the person making the correction.

• The date and time of the correction.

Corrections should include a brief note explaining why the change was made. For example:

• “Incorrect time documented, corrected to reflect administration at 9:00 a.m.”

• “Patient’s middle initial recorded incorrectly, updated to match ID card.”

This ensures transparency and prevents accusations of record tampering.

In some cases, errors may affect treatment decisions or billing. For significant corrections:

• Notify the treating provider immediately.

• Inform the patient if the error impacts their care plan.

• Correct related claims or billing documentation.

Case Study: Improper Record Alteration

A small rehabilitation clinic faced significant regulatory action during a CMS audit after surveyors identified multiple patient records that had been scratched out and rewritten without initials, dates, or any explanation of the changes. Although staff members explained to surveyors that they were simply correcting clerical or typographical errors, the absence of proper documentation made the alterations appear questionable. This raised serious concerns about the integrity, reliability, and accuracy of the medical record. CMS stressed that medical records must always include clear notations for corrections to avoid the appearance of tampering. The lack of compliance with basic documentation standards ultimately led to findings of deficiency and a requirement for corrective action.

Consequences

• CMS issued a deficiency citation under § 482.24(b)(4), which requires that all entries in the medical record be accurate, complete, and properly authenticated.

• The clinic was required to submit a corrective action plan detailing how staff would be retrained and how records would be audited going forward.

• All staff underwent retraining on proper correction procedures, including how to document changes with initials, dates, and reasons for the amendment (42 CFR § 482.24(c)(1)).

• The altered records also created complications in a malpractice claim, where the plaintiff’s attorney pointed to the irregular entries as evidence of negligence. The clinic incurred significant legal defense costs as a result.

Lesson Learned

This example demonstrates that even well-intentioned efforts to “fix” mistakes in patient records can create compliance risks if not done correctly. Medical records must reflect both transparency and accuracy. Proper training and monitoring are essential to ensure that every correction is defensible, traceable, and compliant.

1. Erasing or Deleting Entries

• Violates CoP and HIPAA requirements.

2. Backdating Corrections

• Creates an impression of fraud or tampering.

3. Failure to Authenticate

• Corrections without initials, dates, or electronic signatures are noncompliant.

4. No Explanation Provided

• Corrections without context confuse auditors and providers.

5. Over-reliance on Copy-and-Paste in EHRs

• Can perpetuate errors instead of correcting them.

1. Develop a Written Correction Policy

• Clearly outline procedures for paper and electronic records.

2. Train Staff Annually

• Include correction scenarios in compliance training.

3. Leverage EHR Features

• Configure systems to block unauthorized overwriting.

4. Perform Record Audits

• Review samples quarterly to ensure compliance.

5. Engage Patients in Transparency

• Encourage patients to review their records and report errors.

Compliance requires more than procedures, it requires a culture of openness. Small practices should emphasize:

• Transparency in handling errors.

• Encouraging staff to report mistakes without fear.

• Reinforcing that proper corrections strengthen patient trust.

By making record corrections part of patient safety culture, small clinics can align clinical excellence with regulatory compliance.

Under 42 CFR § 482.24(b)(4), small practices must correct medical records in a way that preserves integrity, transparency, and accuracy. The only CoP-compliant method is to leave the original entry visible, document the correction clearly, authenticate it properly, and explain the change.

Improper corrections, such as erasing, deleting, or backdating, create compliance risks, legal vulnerabilities, and reputational harm. By following the step-by-step guide, using checklists, and building a culture of accountability, small practices can ensure compliance, protect patients, and prepare confidently for CMS audits.

Consider leveraging a compliance automation tool to streamline your efforts. Such platforms help you document and manage obligations, conduct regular risk assessments, and remain audit-ready, reducing liabilities while signaling accountability to regulators and patients alike.

1. 42 CFR § 482.24 – Condition of Participation: Medical Record Services. Legal Information Institute

2. Office of Inspector General (OIG) – Compliance Program Guidance for Individual and Small Group Practices

3. Admission, Discharge, and Transfer Patient Event Notification Conditions of Participation (CoP) (42 CFR 482.24(d), 482.61(f), and 485.638(d))