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Topic: Develop a late entry policy to ensure compliance

HIM Connection, February 12, 2008

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A key point to address in your late entry policy is the proper format and notation to indicate that it is a late entry, says Kurt Patton, MS, RPh, former Joint Commission executive director of accreditation services and principal of Patton Healthcare Consulting, LLC, in Glendale, AZ. There should be no attempts to backdate an entry or insert a late entry between lines or in the margin of a chart form. The provider should fully document the late entry with the date and time of the observation and clearly identified as a late entry with the date and time. Prohibitions should also exist for backdating or predating medical record entries. From an accreditation perspective, you want to avoid any appearance of falsification, because Accreditation Participation Requirement (APR) 10 carries a harsh penalty of preliminary denial of accreditation. Medical record entries that appear falsified represent additional credibility burdens should a lawsuit eventually arise from the care provided.

The Joint Commission (formerly JCAHO) standards and CMS' Conditions of Participation (CoP) provide relatively little guidance about how to document late entries. The CoP states the following in Section 482.24(c)(1): "All entries must be legible and complete and must be authenticated and dated promptly by the person [identified by name and discipline] who is responsible for ordering, providing, or evaluating the service furnished." The Joint Commission states a similar expectation in standard IM.6.10, EP 8: "The hospital should have a policy on the timely entry of information into the patient's medical record."

Most hospitals probably have a policy that is compliant with both CMS and Joint Commission expectations, but this doesn't help guide you when you have missed the promptness expectation. CMS, in a sense, sets the outer limits of lateness by stating that the medical record should be complete 30 days after discharge. Practically speaking, this 30-day time frame also stretches the boundary of plausibility for an individual to be able to document the specifics about a care episode from either memory or handwritten notes.

Editor's note: This topic was adapted from the February 2008 issue of Briefings on The Joint Commission. For more information, visit http://www.hcpro.com/content/204952.cfm.

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