Medical Record Documentation: Time is of the Essence

What is the appropriate time frame for completing medical record documentation in the office setting? According to Medicare, “the service should be documented during, or as soon as practicable after it is provided, in order to maintain an accurate medical record.”1,2 So, what is considered “as soon as practicable,” or “timely and reasonable?”  Although the Centers for Medicare & Medicaid Services (CMS) does not provide any specific period to reflect “as soon as practicable,” some Medicare fiscal intermediaries (FIs) have defined a reasonable time frame as 24-48 hours.3

Providers should comply with this guideline and complete documentation in a timely manner. Those responsible for coding and/or entering charges need to be cognizant of the timeliness of medical record completion. Some have suggested that it may be unreasonable to expect a provider to recall the specifics of a service two weeks after the service was rendered.4

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If you are not a Medicare provider, you may think that you do not need to adhere to these documentation requirements. However, be aware that other payors and organizations tend to follow Medicare requirements and recommendations.

Medical record “charting” seems simple, but the process has many pitfalls. A significant dual challenge is to chart in a timely manner while still providing care to the patient.5 Many cases show that careful and contemporaneous medical charting is the best way to prevail when a dispute arises over patient interactions.⁶ Failing to document in a timely manner can have serious repercussions. According to California Business and Professions Code § 2266, “The failure of a physician and surgeon to maintain adequate and accurate records relating to the provision of services to their patients constitutes unprofessional conduct.”

Additionally, the Medical Board of California (MBC) investigates complaints and can impose disciplinary action for poor or lack of medical record documentation, which can be posted to your public record on the MBC website. 

One example of failing to comply with timely documentation of a patient encounter involves a physician who received an after-hours call from a patient complaining of a severe headache. The physician instructed the patient to go to the emergency room (ER) for an evaluation. The patient responded, “Okay,” but never went to the ER as instructed and had a massive cerebrovascular accident (CVA) later that night. The patient subsequently sued the physician, alleging that the physician did not direct her to go to the ER. Her allegations were backed by a friend’s witness testimony. Unfortunately, the physician did not document the content of the phone call or her instructions to the patient. If the physician had simply documented this conversation, the physician may have avoided a lawsuit. Good documentation practices are vital and include: (1) whether it is a late or delayed entry; (2) the date and time of the note; (3) the date and time of service; (4) the type and method of service; (5) details of the encounter; and (6) any instructions given to the patient. For EMR, even if the entry date is automatic, you still need to identify the notation as a “late entry” and include the elements above.7 Remember, documentation speaks volumes for one’s defense.

Contrast the previous case with another case involving another physician who determined that a patient needed a test performed ASAP. During an office visit, the physician informed the patient of the urgent need for a specific test, and the importance of getting the test performed. The patient agreed and the physician called the testing facility to schedule the appointment while the patient was in the office. The physician expected the test results in two days and kept the patient’s medical record on his desk as a reminder to follow up. When the results did not arrive as expected, the physician called the testing facility and was informed that the patient did not show for the scheduled test. The physician promptly called the patient’s home and was informed that the patient was in Europe. During the patient’s trip, she became extremely ill. The patient subsequently attempted to sue the physician for failing to tell her the importance of completing the test in a timely manner. However, the physician had meticulously documented his conversation with the patient during the last visit, including: the patient’s understanding and acceptance of having the test performed urgently; the call made to the testing facility to schedule the test; and his call to the patient’s home when the patient failed to show up for the test. Due to the physician’s detailed documentation of events, the physician avoided the lawsuit. It became evident that the patient did not want to miss her trip to Europe, a planned trip she had not mentioned during her visit with the physician.

Timely documentation helps to provide you and others with a more accurate and informed timeline of your patient services and encounters. More importantly, it can help you mitigate the risk of certain claims and allegations. Completing and signing off on charts within 24-48 hours is a good risk strategy to avoid unfinished charts slipping through the cracks. Without proper and timely documentation, you may jeopardize both your payment for services and ability to defend against certain claims.   

 

Dona Constantine is a Senior Risk Management and Patient Safety Specialist for CAP. Questions or comments related to this article should be directed to DConstantine@CAPphysicians.com.

References:

1Medicare Claims Processing Manual Chapter 12 - Physicians/Nonphysician Practitioners Medicare Program (Revised 3-4-22). https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/...

2NOTE: These Medicare guidelines are for general medical office practice settings. This article is not intended to address documentation requirements for specific forms, e.g. completion of H & Ps in a hospital setting, etc.

3Complete and Timely Documentation of Medicare Services, WPS Government Health Administrators. Published Nov 10 2017, Last Updated May 07 2019.

4Pelaia, Robert Esq., CPCO, “Medical Record Entries: What Is Timely and Reasonable?” September 1, 2013, Medicare Comment No 1 blog/25667. https://www.aapc.com

5ECRI. Documentation: a primer on charting in the medical record. Ambul Care Risk Manage 2020 Apr 13. https://www.ecri.org/components/PPRM/Pages/EHR4.aspx

6Ownby, Gordon, CAP. Medicine on Trial 1st edition “He Said, She Said.” p. 58.

7Medicare Program Integrity Manual Chapter 3 - Verifying Potential Errors and Taking Corrective Actions Table of Contents (Rev. 11032; Issued: 09-30-21). https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c03.pdf