The provider at my clinic is from a much older generation. As such, he has been rather slow to embrace EMR and relies heavily on his handwritten notes when examining patients. After the encounter, the medical assistants input his handwritten notes into the patient’s EMR and make sure every scrap of written documentation- from his notes, to the scripts, to any radiology, etc.- has been scanned into the computer and attached to the patient’s chart.

As the coder/biller/auditor, I then code the encounter and check it for accuracy. It is then presented to the provider for his final approval and to be electronically signed. It’s an overly drawn out process for something that really shouldn’t be so complicated.

How long is too long to complete this process? I ask because sometimes we get patients who want all of this documentation in their hands the day of the visit- not just the vitals or a quick summary. Legally, is there a timeframe for us to follow to comply with their request?

Thanks!