The Document Date is used to help classify the medical record page’s date, and in essence, the date in which the encounter occurred. It is a crucial step in the workflow of processing an RP# as it aids in the organization of patients’ data, that is presented to the end user or client.
Note: A date is required for all Medical pages. ‘Other’ document types do not need a date.
To accurately identify dates, we can reference key criteria:
- The Document Date is the Date of Service the patient received medical services.
- Look for context clues and keywords within the records:
- Visit Dates
- Encounter Dates
- Consult Dates
- Note Date
- Collected Date
- Exam Date
- Visit date
- Observation Date
- Procedure Date
- Surgery Date
- Operation Date
- Treatment Date
- Admission Date
- Discharge Date (Last Date of Service)
- For date format, always use MM/DD/YYYY.
- Keep entire encounter intact.