[JKDON]

How do you view late entries. Example: if the documentation is minimal and skimpy, but there is a late entry after a resident is transferred to the hospital (say from the nursing home) which is long and extremely comprehensive. How much weight do you give that entry. It is possibly a CYA entry, but very well could reflect what care was given and the assessment at that time. It would appear that the accepted standard is the skimpy and minimal entries most often seen in the record, and then this one magnificent entry is placed after the transfer out. I know that all late entries are a little suspect, but if it answers the question, do you take the information into account, and do you take it at face value?
From a litigation perspective and or regulatory compliance perspective. How would you view this kind of an entry?

[sirI]

Originally Posted by JKDON

How do you view late entries. Example: if the documentation is minimal and skimpy, but there is a late entry after a resident is transferred to the hospital (say from the nursing home) which is long and extremely comprehensive. How much weight do you give that entry. It is possibly a CYA entry, but very well could reflect what care was given and the assessment at that time. It would appear that the accepted standard is the skimpy and minimal entries most often seen in the record, and then this one magnificent entry is placed after the transfer out. I know that all late entries are a little suspect, but if it answers the question, do you take the information into account, and do you take it at face value?
From a litigation perspective and or regulatory compliance perspective. How would you view this kind of an entry?

Excellent question, JKDON,

As you know, the medical record (MR) is like a witness in the court room.

Anytime there is a late entry it can possibly be viewd as evidence tampering. Tampering will in turn strengthen the plaintiff's case dramatically by making the defendent look dishonest or deceitful. The plaintiff can then seek punitive damages. And, most jury's will respond to said tampering with anger and out of proportion awards for damages in relation to actual injury sustained.

Not only would you look for late entries, but, a "too neat" handwriting with the late entry. An over zealous explaination in the entry (like you said, a magnificent entry). A too consistent approach to the entry. Late entries are squeezed in or obviously added later. Additional pages with late entries are added after the fact. And, if the entry was made weeks or months after the incident.

The LNC would want to request other medical records to compare entries by the same individual and the entity policy of late entries. Also, you might want to see medical records of patients hospitalized on a particular unit or seen by a particular nurse/physician on the same day and compare.