Forum - Questions & Answers

Apr 3rd, 2009 - bnicoletti

Unfinished chart notes

We know that the CMS Claims Processing manual says that the documentation should be done as soon as practicable after doing the service, or words to that effect.

My question is: what rules do you have in your organization about how soon the chart must be complete? Have these changed since using an EMR, if you are using one?

Apr 4th, 2009 -

No rules here

7 doc private practice on an EMR.

We have no set rules- every doc knows the consequences of being audited and the auditor finding that the notes do not match the visit level chosen. If they think they will look nice in stripes, they are welcome to leave their notes incomplete.

I personally finish every note after the visit and check them all at the end of the day so I don't face a huge number of notes to complete at the end of the week. It's like your kids and their bedroom; if they keep it clean it's not a problem. If they are asked to clean it every week or month, they throw a tantrum and do a bad job.



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