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 21st CURES Act, an unreasonable delay in a patient/caretaker’s ability to get a copy of their medical notes could be considered information blocking.
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:
Which drug, drug classes (i.e., sulpha drugs) and vaccines to avoid in the futur
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