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Printed Date: 9/22/2015
Entering information into patients’ medical records in a timely manner is important for many reasons. The Centers for Medicare & Medicaid Services (CMS) provides some guidance regarding what is considered 'timely,' for Medicare purposes.
We strongly encourage all health care providers to enter information into the patient’s medical record at the time the service is provided to the patient; that is, contemporaneously.
CMS recently published 'established recordkeeping principles' to provide further guidance regarding the timeliness of entries in medical records. These principles apply to all Medicare contractors that review medical records, including: Medicare Administrative Contractors (MACs), to include Palmetto GBA; the Comprehensive Error Rate Testing (CERT) review contractor; Recovery Audit Contractors (RACs) and Zone Program Integrity Contractors (ZPICs). In all cases, regardless of whether the documentation is maintained or submitted in paper or electronic form, any medical records that contain amendments, corrections, or addenda must:
For paper medical records:
For electronic medical records:
Medicare contractors, including Palmetto GBA, cannot consider entries in medical records that do not comply with these established recordkeeping principles, as described above; for example, we must disregard undated or unsigned entries handwritten in the margins of a document.
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Last Updated: 01/11/2018