Delayed Physician Documentation in Medical Records
Penalty
Summary
The facility failed to ensure that physicians accurately dated their progress notes at each required visit, resulting in discrepancies between the effective date of service and the date the notes were created in the electronic medical record (eMR). For three residents with varying degrees of cognitive impairment and chronic medical conditions, physician progress notes were entered into the eMR days to months after the actual date of service. For example, one resident's progress note had an effective date a month prior to its creation date, while another resident's notes were created weeks after the documented visit. In one case, multiple progress notes for a resident were entered on the same day, but with effective dates spanning several months prior, indicating a significant delay in documentation. Interviews with facility staff confirmed that physicians visited regularly and were responsible for entering their own progress notes into the eMR. One physician explained that their documentation was maintained in a separate electronic health record system, accessible only to select staff, and was later transferred to the facility's eMR. The Director of Nursing acknowledged concerns regarding the timely availability of medical records. The facility's policy requires that physician progress notes be maintained according to professional standards, but the observed practice did not align with this requirement.