Provider documentation standards and requirements for patient medical records

¶ … Provider Document Guidelines)

Provider Documentation Responsibilities

Summary of Key Concepts

Authentication of patient record entries

All entries in the medical record must contain the author's identification. Author identification may be a handwritten signature, unique electronic identifier, or initials.

Abbreviations used in the patient record

All abbreviations use should be kept to an absolute minimum for effective and safe communication in patient care. Abbreviations should be avoided completely especially in drug prescriptions, operation lists and consent forms -- for example, the laterality of site of operation. Lists of approved abbreviations and their correct meaning should be established along with a list of 'Do not use' abbreviations to be followed by the healthcare professionals.

Timeliness of patient record entries

All entries must be dated. Documentation should be generated at the time of service or shortly thereafter. Delayed entries within a reasonable time frame (24 to 48 hours) are acceptable for purposes of clarification, error correction, the addition of information not initially available, and if certain unusual circumstances prevented the generation of the note at the time of service.

Amending the patient record

To properly execute a medical record addendum, the provider must, at a minimum, write the following details in the medical record:

The date the record is being amended.

The details of the amended information.

A statement that the entry is an addendum to the medical record (it is not appropriate to add an addendum to the medical record without identifying it as such).

The date of service of the service being amended.

The medical record should be amended within a reasonable period of time that would allow the provider of service to recall the specific details of the patient encounter. Medical record addendums should be an exception rather than a routine or recurring part of medical record documentation. Medical record addenda must be properly identified and reference must be made to the original note being amended. Failure to properly amend the medical record may give the appearance of "falsifying documentation," which is considered fraudulent.

The Health Care Record? Reading Assignment-Green, N.A. & Bowie, M.J., Textbook & Lab Manual, Chapter 4-5?