I am often asked about what the standards are for completion of progress notes. I know, there are all sorts of stresses on clinicians to effectively treat each client, with a very tight window between appointments to complete documentation. And yet there is a general expectation that the progress notes are completed “at the time of service or shortly thereafter” per CMS.
While CMS will allow for progress notes to be completed within 24 to 48 hours of the session, at least some insurance companies expect the progress notes to be completed within 24 hours. Anything over 24 hours requires documentation in the note that it was a delayed entry.
Progress notes with extended lengths of time to completion (beyond 24 or 48 hours) can, under scrutiny of an audit, be considered an unreasonable delay, so you definitely want to avoid this as a pattern. You may be able to get some forbearance when this occurs rarely or occasionally, but if all of your notes are delayed, you could run into an unfavorable outcome of an audit.
So, as you look at your progress note documentation -- as well as your scheduling -- approach, find the balance between meeting medical necessity goals with the ability to complete those notes within the time you make to complete them.