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
If you are in CA the Title 22 Regulation is "records are to be completed within 2 weeks after discharge"
Your facility can change it as long as it is not outside of the 2 weeks. One of my facilities is looking at within 36 hours in order to be in line with the new federal regulations that was recently delayed.
Lorraine C. Wilson, RHIA
Systemwide Director HIMS Operations
Document Capture/Physician Record Completion-Regulatory/Forms Development
(619) 260-7325 (SD)
(619) 518-8088 (Cell)
Melissa,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.