Physician Requirement to Document Date of Service on Operative Reports: Q&A With Cindy King of Health Inventures

Cindy A. King RN, CPHQ, is assistant vice president of clinical, quality and compliance for Health Inventures.
 
Q: We have a physician in our ambulatory surgery center who refuses to document the date of service on her dictated operative reports. Is there any specific requirement for her to document the date of service on her dictated op reports?
Cindy King: According to the ASC CMS regulations (42 CFR 416.47 (Condition for Coverage: Medical Records)), it states that “The ASC must maintain complete, comprehensive and accurate medical records to ensure adequate patient care.” Also, most accreditation organizations have standards that mandate the ASC maintain complete and accurate clinical records and that entries and/or paper-based records are authenticated by the author and dated accordingly, which could also demonstrate documented evidence for incorporating this information into the record in a timely manner. Additionally, from a community standard perspective, most facilities have corresponding medical record policies and procedures that address this type of detail, and lastly, whenever a practitioner applies and/or re-applies for medical staff privileges, there is usually verbiage included in the facility’s medical staff bylaws and/or their attestation form on the application/re-application that they agree to abide by all of the ASC’s policies and procedures.