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.
Access the full story in the February issue of Briefings on The Joint Commission; access is free for subscribers, nonsubscribers can sign up for a 30-day free trial of BOJExtra! or purchase a copy of the story for $10 by clicking here.
0 comments on “Definitions and rules for late entries ”
- Complications from immobility by body system
- Differentiate between types of wound debridement
- Note similarities and differences between HCPCS, CPT® codes
- What does case-mix index mean to you?
- Pneumonia with a negative chest x-ray: Clinical diagnoses, physician documentation, and coding guidelines
- OB services: Coding inside and outside of the package
- Don’t forget the three checks in medication administration
- What is the difference between an IPA and a medical group?
- Fracture coding in ICD-10-CM requires greater specificity
- ICD-10 tip: Coding for infectious and parasitic diseases
- How coders can build a successful relationship with their physicians
- Note from the Instructor: Provider-Based vs. Freestanding Locations: Financials Flip-flop with New Packaging
- No Match, no problem: Recruitment and beyond
- Improve documentation with 15 tips for timely record completion
- HIPAA: Safeguard Residents’ PHI
- Got stickers? How one PA hospital uses labels to reduce medication errors
- Follow these tips to properly report bladder catheter codes
- Clinical competency committee composition
- Charge for venipuncture separately
- Alarm management plans that improve patient safety