Have you ever wondered if it is acceptable to add medical record documentation after the service has been provided and if so, how long after the service was rendered it is appropriate to add information? This issue has been addressed in the
Center for Medicare and Medicaid Services (CMS) Program Integrity Manual (PIM) which provides guidance to contractors hired by CMS to audit medical record documentation.
The PIM instructs Medicare auditors to give less weight when making review determinations to documentation created more than 30 days following the date of service. The guidance goes on to state that providers who have a pattern of making entries more than 30 days after the date of service may need to be referred to the Medicare contractor responsible for investigating potential fraud cases.
The following tips apply to late entries in the medical record:
• Identify the new entry as "late entry."
• Enter the current date and time. Do not try to give the appearance that the entry was made on a previous date or time.
• Identify or refer to the date and incident for which the late entry is written.
• If the late entry is used to document an omision, validate the source of additional information as much as possible (e.g., where you obtained the information to write the late entry).
• When using late entries, document as soon as possible. The more time that passes, the less reliable the entry becomes.