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!

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    Melissa Chappell, RHIA
    Director of HIMS Operations,Vidant Health
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  • 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

     

    Thanks,

    Karla

     






  • 3.  RE: Record Completion Timeframes

    Posted 14 days ago
    Do hospitals set there own time frames for H&P, discharge summaries and OP notes to be dictated by or does each state have a rule on that. My facility right now for H&P is 24 hours Op note 24hrs from end of procedure , discharge summary in 24 hours but then we have on discharge summary a 15 days for completion before chart is delinquent. We want to change that I was told by another HIM from another facility that it was law that they have 15 days to complete.

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    Amy Lee
    Him
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  • 4.  RE: Record Completion Timeframes

    Posted 13 days ago

    Amy,

    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

    Scripps Health

    Systemwide Director HIMS Operations

    Document Capture/Physician Record Completion-Regulatory/Forms Development

    (619) 260-7325 (SD)

    (619) 518-8088 (Cell)

    https://scrippshealth.sharepoint.com/sites/ScrippsConnect/SitePages/Introducing-a-New-Way-to-Scan-Documents-into-Epic.aspx.

     

     

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  • 5.  RE: Record Completion Timeframes

    Posted 13 days ago
    We are in KY






  • 6.  RE: Record Completion Timeframes

    Posted 12-12-2019 11:05

    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. 



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    Mayra Allemond
    Him Director
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  • 7.  RE: Record Completion Timeframes

    Posted 13 days ago
    I would also check with Joint Commission (JC).

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    Beverly Seal
    Supervisory, Medical Records Admin
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