Wiki Date of service on each hospital note...

[wjensen]

Hi All,
Does anyone know where I can find documentation that states that the Physician must date every note entered in the medical records whether it is hospital progress notes, surgeries, consults and practice progress notes as well. Most of our hospital based physicians date everything but some of the notes have a dictated date and no date of service.
We can't rely on the dictation date because it is not always the date of service. Any help on getting something to share with the Docs would be appreciated.

Thanks
Wanda J.

 

[cmcgarry]

Hi All,
Does anyone know where I can find documentation that states that the Physician must date every note entered in the medical records whether it is hospital progress notes, surgeries, consults and practice progress notes as well. Most of our hospital based physicians date everything but some of the notes have a dictated date and no date of service.
We can't rely on the dictation date because it is not always the date of service. Any help on getting something to share with the Docs would be appreciated.

Thanks
Wanda J.

Hi Wanda,
The second page of the 95 Documentation Guidelines - #2 - states
"The documentation of each patient encounter should include date and legible identity of the observer." On the first page, they note that these principles are applicable to all types of medical and surgical services in all settings.
These are also listed on page 3 of the 97 Documentation Guidelines.

I hope this helps,