Late progress note do's and don'ts
Medicare's Program Integrity Manual allows a late note when its date and author show. Backdating the note hides when you wrote it.
Co-founder, JotPsych
You're finishing Monday's and Tuesday's progress notes on Friday afternoon. Each note gets your name and your electronic signature.
Medicare's Program Integrity Manual guides the contractors who review Medicare claims, and its chapter 3 covers late notes.
Write each note on the visit day when you can.
Let a late note show its real date.
Put each change in a dated amendment.
Dating a late note as the visit day.
Overwriting or deleting a signed note.
Letting anyone else sign under your name.
Each item rests on chapter 3 of the Medicare Program Integrity Manual. A reviewer who finds a potentially fraudulent note refers the case to Medicare's fraud investigators.
Do these three
- Write each note on the visit day when you can. The manual says "All services provided to beneficiaries are expected to be documented in the medical record at the time they are rendered." Late notes are the occasional exception.
- Let a late note show its real date. The manual calls a late note a delayed entry and says "The date and author of any amendment, correction or delayed entry should be identifiable." Sign the note the day you write it.
- Put each change in a dated amendment. Reopen your note, make the change, and sign again. The manual wants each change "clearly and permanently denoted." Your amendment then carries its own date and author.
Date of service: Monday
Signed: Friday, 4:12 PM, by the treating clinician
Amendment: the next Tuesday, 9:05 AM, by the same clinician
Date of service: Monday
Signed: Friday Monday
Change: made the next Tuesday, with no date or author shown
In the first note, the signature and the amendment each carry a date and an author. In the second, a reviewer can't tell that the note was signed four days late or changed after that.
Avoid these three
- Don't date a late note as the visit day. In a federal complaint filed in Detroit on September 22, 2026, a witness says a substance use recovery provider's owner ordered fake progress notes for a Medicaid plan's audit. The owner also had the files backdated, the witness adds. The government seeks about $18.8 million it calls fraud proceeds.
- Don't overwrite or delete a signed note. The manual says providers need a system and software "protected against modification." Use a record system that keeps the signed version when you change it.
- Don't let anyone else sign under your name. The manual warns of "misuse or abuse" with electronic signatures. You and your practice "bear the responsibility for the authenticity" of what your signature attests.
Open five notes you signed after the visit day. Check each signing date. Then check that each change sits in an amendment.
Notes you sign in JotPsych show your name and the time, and an amendment keeps the original on record.
See JotPsych- Centers for Medicare & Medicaid Services, Medicare Program Integrity Manual, chapter 3, sections 3.3.2.4 and 3.3.2.5.
- United States Attorney for the Eastern District of Michigan, complaint for forfeiture, No. 26-cv-13589, filed September 22, 2026; allegations, no criminal charges.