The requirement of the law that is most troublesome to medical records administrators is that the entry be made at or near the time of the act, event or condition described in the entry. There are no rigid legal guidelines on how soon after the event the entry must be made in the record. The courts discuss this in terms of a reasonable delay, without putting a specific time limit on what is reasonable. Almost all hospitals specify the maximum time allowed for completion of the medical record after the discharge of a patient. This is typically a 30-day period, during which the physician is expected to complete the chart. It is expected that the courts would give very strong weight to the requirement of 30 days (except for order that must be countersigned within 24 hours) as the definition of a reasonable period to make the entry. Unfortunately, most hospitals have great difficulty in getting all patient charts completed within the 30-day period. As noted later in our discussion of JCAH standards for medical record keeping, incomplete charts are considered a serious violation of medical records protocol.
Incomplete chart entries can also be the basis for the exclusion of late entries from evidence in a legal proceeding. For example, it is not uncommon for an attorney to request copies of the medical record several months after the patient has been discharged from the hospital. Upon receiving the attorney's request, the medical records department discovers that the physician has never completed the chart. The physician is notified that an attorney has requested the records and that the physician should complete the chart as soon as possible. Fearing a lawsuit, the physician dictates an elaborate, and often self-serving, discharge note. The attorney then reviews the records and notes that the date of dictation is months after the date of discharge and is, in fact, after the date the records were requested. This causes the attorney to disregard the contents of the discharge note as self-serving. If the attorney can convince the court that the discharge note was made after an unreasonably long delay, the court may be willing to exclude the discharge note from evidence. This presents the health care provider with the problem of not being able to establish clearly the patient's condition upon discharge. It also increases the likelihood that the hospital would be found to be in dereliction of its duty to ensure quality of care by failing to demand that the discharge note be written within the required time period.
When it has been determined that a patient hospitalized in the facility may have suffered an injury due to medical negligence, special care should be taken to ensure that the medical record is promptly completed. This precaution m ay prevent the problem of not being able to use the chart in court because of the delay. Discharge summaries and other dictation made after the patient's injuries become obvious are often taken to be self-serving and have much less credibility before a jury than entries that are made promptly in the usual course of rendering care. Since juries tend to distrust records made after the fact, it is an important part of risk management to avoid late entries into the medical record.
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