I work in a critical access hospital as an inpatient coder and also as a documentation improvement specialist. One of our admitting providers has a very bad habit of not completing his H&Ps or Discharge Summaries in a timely manner; it is not uncommon for him to complete his documentation MONTHS after the patient has left. Obviously this leads to inaccuracies/inconsistencies in his documentation as well as billing delays.
Is this normal? Is this allowed at other hospitals? The administration at my hospital is giving the impression that this is no big deal, and there are no consequences for this provider. I am at a loss because I can't figure out how I'm supposed to improve documentation that doesn't exist, much less code these inpatient charts. I would like to present some information at my next Quality Meeting showing that this is not an acceptable practice (because it's not, right?) but I can't find a good answer from CMS. Any help that ya'll can give me with this would be so appreciated.
Is this normal? Is this allowed at other hospitals? The administration at my hospital is giving the impression that this is no big deal, and there are no consequences for this provider. I am at a loss because I can't figure out how I'm supposed to improve documentation that doesn't exist, much less code these inpatient charts. I would like to present some information at my next Quality Meeting showing that this is not an acceptable practice (because it's not, right?) but I can't find a good answer from CMS. Any help that ya'll can give me with this would be so appreciated.