Alteration includes adding, changing, or deleting entries after the documented time. Legitimate late entries are permitted when identified as such with the actual entry date, while undisclosed alteration is not.
Electronic audit trails record modification history.
Alternative Names:
Record Alteration, Altered Medical Record
Why it Matters?
Audit trails make alteration detectable in ways paper records did not, recording every access and change with timestamps. A provider who modified a record after learning of a claim has created a problem far exceeding the underlying care issue, since it supports spoliation instructions and destroys credibility on every issue. Obtaining the audit trail rather than the printed chart is accordingly a standard request.
Frequently Confused with
Related terms
Frequently asked questions
How is alteration detected?
What are the consequences?
