Health Information Management

Q&A: Policies for late entry documentation

CDI Strategies, May 27, 2010

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Q: Payers have been pushing back when a diagnosis appears in the discharge summary and not in the chart. Can the physician add a late entry or addendum into the medical record by way of a progress note or an addition to a discharge summary history and physical? Can you help me with citations for this, as well?

A:The American Health Information Management Association published practice guidelines that address late entries as follows:

 
“Any clinical provider documenting within the health record may need to enter a late entry. The organization should clearly define how this process occurs within their system. Tracking and trending within the electronic record will be dependent on the system; the organization should clearly understand this process.
 
“In addition, specific policies and procedures should guide clinical care providers on how to correctly make a late entry within the health record. The author should document within the entry that it is a late entry.
 
“Typically late entries apply to direct documentation only; for example, physician orders, progress notes or nursing assessments. Dictated reports such as history and physicals, although dictated outside of organizational time frames, would not be considered a late entry.
 
“Note: Some systems may not have late entry functionality. The late entry is shown as an addendum.”
 
The following is an example of one institution’s policy regarding late entries:
When a pertinent entry was missed or not written in a timely manner, the author must meet the following requirements:
  • Identify the new entry as a “late entry.”
  • Enter the current date and time – do not attempt to give the appearance that the entry was made on a previous date or an earlier time.
  • The entry must be signed.
  • Identify or refer to the date and circumstance for which the late entry or addendum is written.
  • When making a late entry, document as soon as possible. There is no time limit for writing a late entry; however, the longer the time lapse, the less reliable the entry becomes.
  • An addendum is another type of late entry that is used to provide additional information in conjunction with a previous entry.
  • Document the date and time on which the addendum was made.
  • Write “addendum” and state the reason for creating the addendum, referring back to the original entry.
  • When writing an addendum, complete it as soon as possible after the original note.
Editor’s Note: This question was answered by Fran Jurcak, RN, MSN, CCDS, a manager with Wellspring + Stockamp, a division of Huron Healthcare in Chicago. Contact her at fjurcak@huronconsultinggroup.com.



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