# full dates on op notes



## sundaey (Jul 21, 2008)

Can someone please tell me what Medicare states about documentation guidelines for writing the full date (with the current year) on all E/M and op notes? I have argued w/ a few people that the year must be included.

I appreciate it.


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## Treetoad (Jul 22, 2008)

Why would you not want to add the year?  My guess is that it wouldn't hold up to an audit without the year.


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## mbort (Jul 22, 2008)

also sounds like a transcription issue


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## dmaec (Jul 22, 2008)

seems silly not to put a year on the documentation.  I've actually gone into my own provider same day, two years apart (I remember, cuz it was my birthday both times)  yeah - not fun birthdays those years! LOL... BUT - what confusion there could be if the date isn't complete.  I think any insurance company, not just medicare will frown upon not having complete documentation - including "date of service".  I agree with Treetoad also, if it was audited, it's not going to go over well!~


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## sundaey (Jul 28, 2008)

well, here's the problem. On the trauma rounds/initials, the pt's sticker w/ the admit date is on, so therefore, some people feel that you need to use common sense where this is. My whole arguement is, why are you being lazy? just use the whole date, which includes the year. I know of someone who bills for a hospital on the east coast that allows there billing to go thru w/out the year. I was just curious as to where there was documentation on the need for the year to be documented.


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