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Timely Entry in the Usual Course of Business

The requirement of the law that is most frequently not complied with is that the entry be made at or near the time of the act, event, or condition described. The courts allow reasonable delay, given the circumstances of the business. Most hospitals use the JCAHO (Joint Commission on Accreditation of Healthcare Organizations) 30-day standard for completing the chart, with certain time-critical entries to be completed in 24 hours. (This does not mean that entries can be backdated. Progress notes and other daily memoranda must be made on the day to which they pertain.)

While the courts would generally ignore this delay, it is certainly questionable whether 30 days is a reasonable delay. Since both plaintiffs and defendants usually want the record admitted to court, there has been little litigation on whether medical records actually meet the requirements of the business records exception.

In theory, the most important requirement is that the records be kept in the usual course of business. This is a twofold requirement: the records must be kept in a standard, well-defined form, and they must be kept as part of the day-to-day activities of the business. This requirement goes to the accuracy of the records. It is assumed that the business does not have an incentive to lie in its routine business records. Once the business's activities are under question, however, it is assumed that there may be some incentive to slant the entries. Self-serving entries that do not relate to the factual basis of a patient's care could be challenged under this requirement.


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