Date of Service Documentation
The date of service should be the date you actually saw the patient (yesterday), not the date you started writing the note (today). The date of service reflects when the clinical encounter occurred, not when the documentation was completed.
Core Principle of Date of Service
The date of service represents when the actual patient encounter took place, regardless of when documentation is completed. 1 This is a fundamental principle in medical documentation that applies across all clinical settings.
- The date of service is the date the clinical event occurred or when the patient was actually seen, not when the note was written or finalized. 1
- Documentation timing is separate from the actual service date—you can complete notes hours or even days after the encounter, but the date of service remains the date of the actual patient interaction. 1
Documentation Best Practices
When completing delayed documentation, you should follow these guidelines:
- Document the actual date and time of the patient encounter in your note, making it clear when the visit occurred. 1
- The timestamp metadata in electronic health records will show when you authored or authenticated the note, which is acceptable and expected. 2
- Include sufficient detail to accurately reflect what occurred during the actual encounter, even though you're documenting it later. 1, 2
Common Pitfalls to Avoid
Several documentation errors can occur when completing notes after the encounter date:
- Never change the date of service to match when you're writing the note—this misrepresents when care was actually provided and can be considered fraudulent billing. 1
- Avoid using copy/paste from other notes without careful editing to ensure accuracy for this specific encounter. 1
- Don't allow delayed documentation to compromise the accuracy or completeness of your clinical record. 1, 2
Electronic Health Record Considerations
Modern EHR systems handle this situation through metadata tracking:
- The EHR will capture both the date of service (when the encounter occurred) and the documentation timestamp (when you completed the note). 2
- Authentication details and timestamps provide a chronological record showing when documentation was completed relative to the encounter. 2
- This dual tracking is standard practice and does not indicate any documentation problem as long as the date of service accurately reflects the actual encounter date. 2