Wiki Medical documentation timeliness

[cfcampbell]

I have been having a problem with some of the physician's charts not being documented in a timely manner. I am trying to find documentation by CMS that states that all medical record entries must be signed and dated (which would also mean the chart has been filled out or dictated) within 48-72 hours. I would appreciate any help with this. CFC

 

[mcpalmeter]

Dear CFC,

The Florida Medicare Administrative Contractor's medical director did publish an article which addressed timeliness of medical record documentation. The article can be found on page 3 of the Third Quarter 2006 issue of the Florida Medicare B Update!

Per the article:

Medicare expects the documentation to be generated at the time of service or shortly thereafter. Delayed entries within a reasonable time frame (24-48 hours) are acceptable for purposes of clarification, error correction, the addition of information not initially available, and if certain unusual circumstances prevented the generation of the note at the time of service.


Also:

All entries must be legible to another reader to a degree that a meaningful review may be conducted. All notes should be dated, preferably timed, and signed by the author.