Late Dictation Policy

Late Dictation Policy

Scope

All physicians, nurse practitioners and physician assistants, and other personnel providing services to patients and submit charges for those services must provide appropriate documentation in a timely fashion.

Purpose

The purpose of this policy is to promote timely completion of clinical documentation in the medical record. The Billing-Coding-Compliance Committee reviews problems associated with delayed dictation. A compliance officer and/or the medical director will monitor this policy.

Policy

All office dictation should be completed and submitted within one day of the date of service.

Procedure

In order to effectively monitor and re-mediate any problems of delay, the Board has

approved the Quality Review Committee’s recommendation to reduce income, where

appropriate, in cases where dictation is delayed without reasonable cause. The

physicians, nurse practitioners, physician assistants and other clinical personnel who provide patient services but have not completed documentation of those visits in the time frame described here are subject to this disciplinary process.

The HAC work list provides an ongoing tally of pending work that is available to the providers at all times. In addition, a weekly report will be sent to all providers reminding them of those items on the worklist that are past due for completion. Those who have not maintained their worklist and responded to the weekly reminder of delayed dictation report will forfeit income as noted herein.

• Chart documentation is due within 1 day of the date of service. Dictation/documentation is considered late if it is not completed within 5 days from the date of service.

• Any late dictation (greater than 5 days past the date of service) will be included in the weekly Missing Dictation Report.

• Any of that dictation listed of the previous week’s Missing Dictation Report that is not addressed timely enough to be off of the following week’s report is submitted to payroll for late dictation penalties. (This now means that dictation that is unfinished 12 days from the date of service will result in reductions in distributable income.)
• Dictation is completed when it is submitted and acknowledged by the system.

• Dictation that returns from transcription should be reviewed (or attested or digitally signed) within 14 days of return to the worklist. Documentation is considered completed when digitally signed or reviewed.

A chart will be listed as “delayed dictation” if the dictation is more than five days beyond date of service and appears on the weekly delayed dictation report. The weekly delayed dictation report is sent to each physician, nurse practitioner, physician assistant, and other personnel providing such services by email. If the physicians, nurse practitioners and physician assistants, and other personnel providing services have not rectified the problem within a week of the reminder, the following may occur at the discretion of the Board:

A. Shareholders - a reduction in income of $25 per chart will be submitted for payroll

adjustment. This process is repeated weekly until dictation is completed.

B. Nurse practitioners, physician assistants, Associate Physicians and other personnel providing services will be subject to forfeiting bonus income in the compensation formula if eligible and progressive discipline according to the Human Resources policy up to and including termination if needed.

This policy also applies to dictation of ancillary service reports. All appeals must be made in person to the Finance Committee.