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Timing of Record Entries – The New Documentation Trap

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Risk managers seek to educate and reinforce the need for timed entries in the medical record to help document sequence and timeliness of care. Often times, Emergency Medical Treatment and Active Labor Act (EMTALA) and other compliance issues, hinge on the timing of various entries; however, hospitals and providers who have not converted to electronic medical records have very few timed entries.

According to the Centers for Medicare and Medicaid Services (CMS), “the timing of medical record entries is crucial for patient safety and quality of care. Timing applies to all medical record entries, not just to the authentication of verbal orders. This would include orders, progress notes, procedure notes, patient assessments, etc. The timing and dating of entries establishes a baseline and timeline for future actions or assessments. Patient medical record entries must be legible, complete, dated, timed and authenticated in written or electronic form.”  Stephen A. Frew, JD, of MedLaw.com, predicts that the first applications of this rule are likely to be encountered in EMTALA investigations in the “Dedicated Emergency Departments” of a hospital—typically ED,OB, Psych, Urgent Care, etc. CMS has always focused very closely on timing, and the lack of timed entries will now be a potential STANDARDS LEVEL violation for medical records, which may also expand into further EMTALA citations.

On the malpractice side, ambiguities in treatment records caused by lack of timed entries may be substantiation for the plaintiff’s attack on the record’s accuracy. Chronicity becomes very important in reconstructing how and when events occurred, and to help defend against attempts to prove that a critical window in time for patient evaluation or treatment was missed.

Risk Management Recommendations:

1. If time/dating of notes is not part of your present charting routine, strongly consider immediately time/dating all office and facility progress notes.
   
   
2. An immediate policy and procedure review should be launched to assess your facility’s exposure. In correlation, ongoing medical records audits, policy changes, physician and staff education, and intense quality auditing will be required in most facilities.

Reference: Revised Appendix A, “Interpretive Guidelines for Hospitals” A-0450 §482.24(c)(1) (Rev.47, Issued: 06-05-09, Effective/Implementation: 06-05-09).