Timely dictation

Does anyone have a link showing the CMS guidelines as to how soon after a visit the dictation needs to be in the patient's chart? I always thought it was 24-48 hours but can't find any definite documentation on this.

Christine M Liles, CPC
Insurance Supervisor

Serving East Tennessee's Dermatology Needs for 40 Years


  • edited May 2017
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    The only official CMS reference is in 30.6.1 "The service should be
    documented during, or as soon as practicable after it is provided in order
    to maintain an accurate medical record."

    Any other time requirements quoted are most likely from local payer policy,
    institutional guidelines or JCHO rules.


    Todd Thomas, CPC, CCS-P ERcoder, Inc

    President 941 NW
    164th, Suite 1

    Edmond, OK 73013

    (405) 749-2633 www.ERcoder.com

  • Under Meaningful Use the guidelines are "as soon as possible" (or
    practicable), I believe. While it makes sense to document immediately after
    the visit, there are too many factors that are brought to bear on an
    absolute standard. Also, most professional liability carriers will advise
    to not delay any longer than necessary for obvious reasons.
    I could find not CMS mandate for an absolute time deadline.
    Bob O.

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