Purpose
Timely documentation supports continuity of care, accurate coding, and patient safety. This is template text to be replaced.
Expected timeframes
- Outpatient encounter notes: completed and signed within 2 business days.
- Inpatient progress notes: completed by the end of the shift in which care was delivered.
- Discharge summaries: completed within 24 hours of discharge.
- Consult responses: documented within the timeframe set by the requested urgency.
Late entries and addenda
- Label any late entry clearly with the current date and time, and reference the date of the original event.
- Use an addendum, not an edit, to add information to a signed note.