Terre Haute Regional ED Chart Completion Policy

1. SITUATION
   • Charting is expected to be complete in timely fashion.
   • Billing opportunities and quality of care are compromised due to late documentation.
2. GOALS
   • We need to maintain an urgency to chart completion.
   • We need to meet expectations which are strict but attainable.
3. EXPECTATIONS
   • Charts will be completed by end of shift as often as possible.
   • 90% of providers’ charts will be complete by 24 hours.
   • 100% of providers’ charts will be complete by 96 hours.
4. PLAN
   • Deficiency audits will be performed frequently.
   • Providers found with 2 or more charts incomplete past 24 hours, or any charts deficient greater than 96 hours will be put in the YELLOW charting deficiency zone.
   • Providers found with 5 or more charts incomplete past 24 hours, or any charts deficient greater than 1 week will be placed in the RED charting deficiency zone.
   • Providers in the Yellow zone will be sent a reminder immediately. Envision leadership will be notified of status.
   • Providers in the Red zone will be reminded daily by phone, text, or email until the charts are resolved. Envision leadership will be updated on status.
   • Providers with persistent non-compliance will be sent a letter asking for a formal response to include an explanation of the deficiency and a plan for improvement
   • Providers may be removed from the schedule for extreme instances of delinquency.
   • Mitigating circumstances will be considered during the above process.

---