How long before a note must be documented


Westerville , OH
Best answers
This may sound like a simple question, but how long after a service is rendered does a clinician have to document that service in the chart? We have a situation where we need to close the books on some services but the clinician hasn't 1) entered any charges, and 2) hasn't even documented the services. :eek: Is there any written rule that gives an answer?
I don't think there is a hardfast rule. But I would say it has to be documented within a reasonable time frame that the provider can accurately recall the event. Days - reasonable. A few weeks - getting into a gray area. Months - unreasonable.
In my opinion, whenever there is a service rendered you have to document it, sign & dated at that time. To be on the safe side. Once you get audit and on that documentation there's no service date or initial date, you can get penalize.