Guidelines for Completion of Patient Encounter, Electronic Medical Record Notes and Fee Tickets

August 14, 2008

The following guidelines should be followed when completing documentation on patient services.

1. Documentation for patient encounters (dictation, handwritten) and fee tickets for encounters should be completed within 24 hours of the service.  Review and authentication of dictation should also be completed within 24 hours so the notes can be scanned into the electronic medical record.
2. Electronic medical record encounters should be completed at the time of service or no later than 24 hours after the encounter.  The completion of documentation is critical for the quality of care of our patients.
3. Each department Chair will be responsible for developing mechanisms to monitor the timely completion of encounters and fee tickets.