Based on Centers for Medicare and Medicaid Services (CMS) Conditions of Participation, a medical record is considered complete if it contains sufficient information to identify the patient; support the diagnosis/condition; justify the care, treatment and services; document the course and results of care, treatment and services; and promote continuity of care among providers.

Per HonorHealth’s Medical Staff Rules and Regulations, all record entries must be completed, dated, timed and authenticated as follows:

1. H&P must be completed within 24 hours or within 30 days and updated accordingly
2. Operative/IR/Cath procedure reports must be dictated immediately after surgery/procedure
3. D/C summaries must be completed within 72 hours of patient D/C
4. Progress notes should be entered daily by the attending physician (or his or her covering practitioner) for all hospitalized patients and as needed to reflect changes in the status of a patient in an ambulatory care setting.
5. Incomplete records, or those needing to be signed/co-signed, become delinquent 30 days post discharge

Having deficient records impacts patient care, safety, coding and billing. As of today, we are holding an average of $54 million for coding and billing due to missing documentation.