Late Entries

I am curious if anyone has a policy that defines a time limit for late entries into the medical record. Our policies are silent on how long from the service date a late entry can be made. Do you take the approach that the 30-day rule for record completion is the limit for making any entry in the medical record?

On a similar note, I am interested to know if any Meditech facilities have solved the problem of how to make a late entry (correction or addition) to a nursing note or assessment after the electronic record is closed (per the system parameters).

Thanks for your insights.

Marianne Dailey, RHIT, CHP, CPHQ
Director HIM & Privacy Officer
Central Peninsula Hospital
Soldotna, Alaska 99669
(907) 714-4563
mdailey@cpgh.org
Sign In to comment.