Q&A: Policies for late entry documentation

May 27, 2010

CDI Strategies - Volume 4, Issue 11

Q: Payers have been pushing back when a diagnosis appears in the discharge summary and not in the chart. Can the physician add a late entry or addendum into the medical record by way of a progress note or an addition to a discharge summary history and physical? Can you help me with citations for this, as well?

A:The American Health Information Management Association published practice guidelines that address late entries as follows:

“Any clinical provider documenting within the health record may need to enter a late entry. The organization should clearly define how this process occurs within their system. Tracking and trending within the electronic record will be dependent on the system; the organization should clearly understand this process.

“In addition, specific policies and procedures should guide clinical care providers on how to correctly make a late entry within the health record. The author should document within the entry that it is a late entry.

“Typically late entries apply to direct documentation only; for example, physician orders, progress notes or nursing assessments. Dictated reports such as history and physicals, although dictated outside of organizational time frames, would not be considered a late entry.

“Note: Some systems may not have late entry functionality. The late entry is shown as an addendum.”

The following is an example of one institution’s policy regarding late entries:

When a pertinent entry was missed or not written in a timely manner, the author must meet the following requirements:

Identify the new entry as a “late entry.”
Enter the current date and time – do not attempt to give the appearance that the entry was made on a previous date or an earlier time.
The entry must be signed.
Identify or refer to the date and circumstance for which the late entry or addendum is written.
When making a late entry, document as soon as possible. There is no time limit for writing a late entry; however, the longer the time lapse, the less reliable the entry becomes.
An addendum is another type of late entry that is used to provide additional information in conjunction with a previous entry.
Document the date and time on which the addendum was made.
Write “addendum” and state the reason for creating the addendum, referring back to the original entry.
When writing an addendum, complete it as soon as possible after the original note.

Editor’s Note: This question was answered by Fran Jurcak, RN, MSN, CCDS, a manager with Wellspring + Stockamp, a division of Huron Healthcare in Chicago. Contact her at fjurcak@huronconsultinggroup.com.

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