Medical Record Documentation

What is the appropriate time frame for completing medical record documentation? Is it acceptable to back time certain charting information? For example, if there was a restraint event three days ago and an internal audit noted today noted that the timing of some of the charting was incorrect, or specific sections of the charting was missing, can the RN/sitter go back and enter that missing charting?

Medical Record Documentation Criteria

We recommend you do not back-time any charting for events on a previous shift or previous shift.  If you do, it will appear to staff and The Joint Commission that you are altering documentation to ensure you look compliant with Joint Commission requirements and your own policies. If your staff is aware of this effort, they could report this to The Joint Commission, which has occurred in other hospitals. This could lead to a decision of Preliminary Denial of Accreditation (PDA), one of the worst outcomes you can get from a survey. If a staff member forgets to chart something, we recommend charting before they leave their shift. For further information, you can find a rule regarding back-time charting in the beginning of The Joint Commission Manual.

Recommendations for Restraint Issues

We recommend that for key issues such as restraint, you implement real-time open record review when you know you have a restraint patient.  This has the added benefit of allowing you to do “just in time” education to a staff person who is not properly adhering to your policies.

A Final Thought

Finally, if your 15-minute, 1:1 documentation is often blank, look to the form design and the expectations you have for staff.  Is the form too much work?  Is there value in what in your current medical records documentation process?  Consider simplifying the form to make documentation easier to comply with.

Patton Healthcare Consulting

Patton Healthcare Consulting provides a complete range of Joint Commission and CMS Compliance Assistance and a full range of pre-survey and post survey services.

We serve more than 350 hospitals, behavioral health care organizations, ambulatory clinics and home care companies nationwide—hospitals ranging from critical access hospitals to the largest health systems. Contact us at (888) PHC-INC1 for more information.