Addendum

What is an Addendum?

An Addendum is a formal, time-stamped addition to a signed Progress Note. It is used to document new or clarifying information that was not included in the original entry.

An Addendum:

• does not modify the original note

• is recorded as a separate, traceable entry

• becomes part of the medical record once reviewed and signed by the provider

Addendum Rules and Risks

All Addendum entries must:

• be created only by the provider

• include date, time, author, and reason

• be recorded as a separate chronological entry

• clearly reference the original note

Key principles:

• The original record remains unchanged

• All updates must be fully traceable

• Addendums should be created as soon as possible (ideally within 24–48 hours)

Risks:

• Delayed entries may be subject to audit scrutiny

• Improper use may be interpreted as inaccurate or non-compliant documentation

• Overuse may indicate poor documentation practices

Propose Addendum

Propose Addendum is a workflow mode that allows authorized personnel to identify and document suggested updates to a Progress Note.

In this mode:

• A user may prepare a proposed update based on identified discrepancies or missing information

• The proposal is not an Addendum and does not affect the medical record

• The proposal is submitted for provider review

Only the provider can:

• review the proposal

• accept or reject it

• convert it into a formal Addendum by signing it

This ensures that all final changes to the medical record remain provider-authorized and compliant.

Addendum Format

For improved readability and clinical usability, the presentation of Addendum entries differs from the traditional approach. The document displays the most current version of the Progress Note, reflecting all accepted updates, followed by a structured Change History that captures each Addendum entry with full audit details.

The original signed note is preserved as a separate record and remains available upon request. This approach maintains full compliance with documentation requirements—ensuring immutability and traceability—while allowing providers and reviewers to efficiently interpret the complete and up-to-date clinical picture without reconstructing it from multiple appended entries.