There may be a myriad of daily occurrences that impact your ability to document. This is a common issue that many Allied Health professionals face. Some of these occurrences might include mounting requirements from insurers, back-to-back scheduled patients, emergency issues, phone calls for prior authorization or other issues which occur daily.
You may think, “I will get to this later.” However, it is important to document as close in time to the patient appointment as possible. Say, for example, you were unable to document a patient’s appointment until the following day, and the patient goes home and contacts you to indicate that an issue occurred. It is far better to have documented the encounter and then add an addendum when the patient contacts you, rather than documenting all in one note. Likely if you are using an EMR, your note will be time-stamped, so it will reflect when the documentation actually occurred.
There are many issues that may impact the timing of when you document. However, timing is important. Be sure to check your profession’s ethical guidelines on documentation principles. When you have questions, it is best to consult an attorney for guidance.
Kristen Lambert, JD, MSW, LICSW, CPHRM, FASHRM
Healthcare Practice and Risk Management Innovation Officer
Trust Risk Management Services, Inc.
NOTE: This information is provided as a risk management resource and is not legal advice or an individualized personal consultation. At the time this resource was prepared, all information was as current and accurate as possible; however, regulations, laws, or prevailing professional practice standards may have changed since the posting or recording of this resource. Accordingly, it is your responsibility to confirm whether regulatory or legal issues that are relevant to you have since been updated and/or to consult with your professional advisors or legal counsel for timely guidance specific to your situation. As with all professional use of material, please explicitly cite The Trust Companies as the source if you reproduce or distribute any portion of these resources. Reproduction or distribution of this resource without the express written permission of The Trust Companies is strictly prohibited.