Forum - Questions & Answers

Jan 12th, 2012 - cbishop 3 

Late documentation

I work for a Hospitalist group. Occasionally they will forget to enter a note in the chart and I discover the omission 2 days later. They add a note to the chart dated with the day they add the note, and then document the day of service. At what point in time is it too late to add documentation?

Thank you

Jan 12th, 2012 -

re: Late documentation

After the chart was copied for the auditor and sent away. Or after the doctor forgets what he/she did. Or whenever your lawyer says it is too late.

I can tell you that bad docs routinely don't dictate H&P's, discharge summaries, op reports until they are about to be suspended, usually at 2 months.

So there is no real right answer...but they are doing right by indicting the time and date they entered it and that it was a late entry



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