Guidelines for Addenda/Late Entries

November 16, 2000

The following are the guiding principles regarding addenda:

1. It is in the best interest of both the patient and the practice that all services rendered are documented as accurately as possible.
2. Faculty should document their participation in patient care fully and in a timely fashion.
3. Where documentation is not sufficient due to exclusion or oversight, billing personnel are charged with contacting the designated point-of-service contact. Should that resource not be available, billing personnel will contact the provider and/or department for direction.
4. Addenda must be properly entered into the original medical record and dated appropriately.
5. A copy of the corresponding note, consult, etc., must be resubmitted to MSRDP/UT Medicine within 48 hours of notice given. However, in the event of medical record delays, inaccessibility of provider, or other extenuating circumstances, resubmission of amended documentation beyond 48 hours may be permitted.
6. Addenda made to the copy of supporting documentation originally submitted to MSRDP/UT Medicine will not be accepted.

7. The opportunity for faculty to complete documentation expires once a charge is keyed to the billing system.

   Example:
   05/01/01 - Addendum to progress note of 04/29/01. Patient seen with Dr. Resident with history of _____________________. On Exam _____________________. Plan of Care _______________________.