Late entry documentation

[JAS]

Hi,

I am looking for any information regarding Home Health Computer generated documentation on late charting. Are there any rules, policies, guidelines, STANDARDS or position statements that say when you can and cannot enter a late entry? If there are guidelines on late charting how late is too late. Is it reasonable or acceptable to chart 3 or 4 months after a pts. discharge? When does it start to look like Fraud or record tampering? There are no P&P from my agency re: Late entry Documentation. This just doesn't sound kosher to me. Any information and direction will be greatly appreciated.

Thank You,

JAS

[rninformatics, DNP, RN]

Consistently "late documentation" demonstrates inadequate practice. If a RFA

(Request for additional Information)notes days and or a weeks delay in your agency's date stamped computer documentation at the very least it could jeopardize reimbursement and at worse result in questions of regulatory incompliance and or fraud.

This "late" documentation, is it clinical data or communication between disciplines?

I would further investigate the reason(s) for lateness of documented care and attempt to resolve the problem(s) that contribute to it. Latenesses in both transcribed/documented physician's orders and changes in plans of care have historically been a problem in Home Health. Documentation that is more than 24 hours "late" should probably be titled an addendum. Of course where information is obtained post discharge that might be relavent to care management or need to be documented for proof of communication then this would not be considered "late".

[Ellen]

If it is a same day late entry..like the dr. finally called back. I'll just add it to the clinical note for that day's visit titled 'late entry' Next day requires a Medical REcord Addendum note. We try to NEVER add to the record after discharge! Doesn't look good..

[CV-RN-CLNC]

if it is truly nursing documentation associated with assessment, observation or intervention your facility may be headed for issues related to maintaining the integrity of their medical records. documentation completed "late" by any definition if found during discovery could be explained to a jury in a manner that would unfavorable. generally back-charting is inappropriate and can be construed self-serving . if patterns are determined and it is noted that the activity is wide spread fines and penalties can be enormous. remember that as a nurse it is your responsibility to know and understand the acceptable stands of practice. if your facility fails to provide you with direction (i.e. policy/procedure) or attempts to encourage you to operate outside of the scope of acceptable practice you should contact your states office of inspector general for more assistance. here are some links that may help http://www.himssanalytics.org/docs/wp_emr_ehr.pdf http://www.nursingcenter.com/pdf.asp?aid=727907

good luck !

[sunrock]

documentation can cost you your job, if a med. is given and not documented = med. error