Awareness : OBC Tips

Medical Record Timeliness: What is Reasonable?

Documentation should be recorded in a timely and reasonable manner.  Medicare expects the documentation to be generated at the time of service or shortly thereafter. Medicare clearly states that “reasonable” means 24 to 48 hours.  Delayed entries within a reasonable time frame (24 to 48 hours) are acceptable for purposes of clarification, error correction, the addition of information not initially available, and if certain unusual circumstances prevented the generation of the note at the time of service.  Providers are urged to comply with this requirement. 

As such, it is important to understand that anything beyond 48 hours could be considered unreasonable. Providers should comply with this requirement and complete documentation in a timely manner. Those responsible for coding and/or entering charges need to be cognizant of the timeliness of medical record completion. It is not reasonable to expect that a provider would normally recall the specifics of a service two weeks after the service was rendered. An entry should never be made in advance.