Q&A: Clarifying RC.02.01.03 EP 5 (Lack of timely documentation)

Q: During our recent survey, the surveyor cited four instances in which the operative notes where not timely, all of which were dictated. How can I clarify this?

A: Consider the following in this case for a clarification:

• If there were no delays in dictation that would clear this finding, was a postoperative note documented at all? Most surgeons will write a brief note postoperatively even when dictating.
• If not, audit the number of procedural notes and compare this to the total number of procedures requiring a note for the 30 days prior to survey to meet the 90% compliance requirement. This citation can be overturned.

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