Q: Is there a rule that says a provider must complete a patients’ chart by a specific time? We have a provider does not complete the medical record in a timely manner. 

A: According to CURI, there are no specific rules about the timing of medical chart completion. However, Medicare providers must follow rules and timing. There must also be a signature. The rule states that providers complete the documentation “during or as soon as practical.” No billing can occur if a service is not recorded or signed off by the provider.  Completion  should take “no more than a couple of days.” Please visit the Centers for Medicare & Medicare Services (CMS) for more information.

For other patients, a provider should complete a patient’s record as soon as possible after each service or visit. This should be done within a 24-hour period. We recommend a maximum time of three workdays or 72 hours. Your practice should set a guideline that is reasonable for all providers, and then monitor compliance to this guideline.

In addition, under the 21^st CURES Act, an unreasonable delay in a patient/caretaker’s ability to get a copy of their medical notes could be considered information blocking.

Q: This is a two part question:

Part 1—A caretaker of one of our patients added other vaccinations on Form 3231 after we signed the form, and then gave the signed form to the school.

Part 2—We then received a request from this same caregiver to put a note in the child’s medical chart that states the child cannot get immunizations because of severe allergic reactions. We have never seen any such allergic reactions. The caretaker never reported a reaction before. We would like to remove (dismiss) this patient from our caseload.

A: If a parent  or legal guardian makes false statements about a child’s health status or falsifies a document, the patient can be removed from your caseload. However, that child cannot not be in a phase of active treatment at the time. You are not required to tell the caretaker why the child has been dismissed and it’s probably best not to do so. Please click here to view a sample letter. 

You can also decline to write a letter stating the child cannot get immunizations because you have not seen any reactions, nor have any reactions been reported to you. However, if the parent is now reporting these severe reactions, you should report them as being noted by the parent. Include that information in the medical record. This documentation should include:

• The common and brand-named drug or vaccine that may have caused the reaction;
• Include the strength and preparation of the item;
• A description of the reaction;
• Date and time of the reaction;
• How many times were the drug or vaccine given?
• How many days passed before the reaction appeared?
• How was the drug given(capsule, injection, etc.)? and

Which drug, drug classes (i.e., sulpha drugs)  and vaccines to avoid in the futur