Health Information Technologies and Processes

Record Completion Timeframes

  • 1.  Record Completion Timeframes

    Posted 11-15-2019 10:24
    I am interested in comparing our record completion time frames with other healthcare facilities - we are a healthcare system composed of 9 hospitals.  I am looking for time frames in which a provider should complete an H&P, Operative Note and Discharge Summary.  If these are dictated, what is the time frame in which the document should be signed? 

    At Vidant Health, we currently have time frames of:
    H&P - 24 hours to be complete, includes signature
    Operative Note - 24 hours to dictate the full note, 3 days to sign
    Discharge Summary - 7 days to dictate, 3 days to sign

    Thank you for your response!

    Melissa Chappell, RHIA
    Director of HIMS Operations,Vidant Health

  • 2.  RE: Record Completion Timeframes

    Posted 11-15-2019 11:31

    Hi, our documents should be signed in order to be considered complete. Our times are as follows:


    H&P- 12 hours of admission

    Operative Report- 24 hours from end of procedure

    Discharge Summary- 48 hours





  • 3.  RE: Record Completion Timeframes

    Posted 12-12-2019 11:05


    Ours are as follow:

    HP- 24 hours from time of admission. Does not include signature.
    Operative Note- 24 hours from procedure.
    Discharge Summary- 30 days from day of discharge. 

    Mayra Allemond
    Him Director