Definitions and rules for late entries

Accreditation Connection, February 8, 2008

Q: Our facility is trying to come to an agreement about how to define a late entry. To be specific, we are looking at when to use a late entry. There are several definitions of a late entry, but we're struggling to find a definition for the time period.

A: The fact that you are struggling with this is good, in the respect that it probably means you have gathered a team of all the involved stakeholders to develop this policy. Including your caregivers, medical records professionals, and risk management staff members will lead to extensive and open discussion and a better final product. I would also encourage your team to examine why you have late entries. Only after you have determined that your expectations are realistic can you address the issue of late entries.

I see many organizations that write policies that sound good, but they have are not capable of uniformly meeting their own standard. That gap between policy and practice leaves your organization vulnerable to many RFI opportunities. Many hospitals are also converting to electronic medical records, which can further complicate the timeliness of medical record documentation if the system doesn't allow for point-of-care data entry, or there is competition for a limited number of data entry devices at the nurse's station.

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