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How long before a note must be documented

  1. #1
    Question How long before a note must be documented
    Medical Coding Books
    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. Is there any written rule that gives an answer?

  2. Default
    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.

  3. #3
    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.

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