Compliance deadlines for clinical documentation, and why it matters

According to standards set by insurance companies, clinical documentation must be completed and signed within 72 hours of each session. In this article, we'll cover why this deadline exists, and the potential consequences in the event of late notes.

Why clinical documentation is important

Clinical documentation serves several purposes, from ensuring prompt payment to providing a record of care. Having clinical documentation that meets insurer standards: 

Gets you paid

Confirming your session is what starts the claims process, which is how you get paid for sessions. Insurers expect all claims to have a note signed within 72 hours of the date of service associated with the claim.

Creates a record of care

Your notes track how a client is doing over time, which helps you better understand how your client’s condition has evolved and make more informed decisions for how to provide the right care moving forward.

Protects you

Whether an insurer needs to review details for past sessions, or a client raises a dispute about past care, your notes allow you to respond to these requests and transparently respond to client concerns, preventing further disagreement or escalation.

Consequences of a late note

Missing the 72-hour deadline for a note can cause the following issues:

Delayed or declined payment

Insurers are more likely to flag, or outright decline, claims submitted with a note signed more than 72 hours after the session.

Less accurate details

The more time that passes between holding a session and writing your note, the less likely you are to remember or accurately transcribe key details, which can lead to problems later, such as when a client raises a question or dispute about a past session.

A note is always required for each session, even if it’s late.

If you submit a note after 72 hours, we’ll ask you to document why you’re submitting after the deadline. You’ll be prompted to include this reason automatically when you use Headway templates.

In most cases, we can still submit claims and make sure you're paid in the event of an occasional missed deadline. However, an ongoing pattern of missed deadlines, or especially failure to provide notes at all, will typically guarantee closer inspection and an eventual audit from insurers.

Signing notes on Headway vs. elsewhere

Signing your note on Headway

Headway provides templates that comply with insurance company standards.

When you Sign and submit a note using Headway templates, we apply an electronic signature and date, which satisfies a key compliance requirement. While you may also choose to Save draft and complete the note later, signing and submitting is still required within 72 hours.

Saving your note somewhere else

Alternatively, you may indicate that your note is saved elsewhere, instead of using a Headway template.

If you choose to keep your note outside of Headway, it's important to remember the note must still be complete and signed within 72 hours of the date of service, no matter which platform you use to write and store it. 

Keep in mind, if you select Note saved elsewhere, you won't be able to use a Headway template for that session's note at a later time. Since you already signed the note outside of Headway, and to maintain integrity and consistency of your documentation, you should not sign a separate version of the same note. Please note: In the uncommon event that we request a copy of your note, you’ll still be able to upload a copy – even if it's saved somewhere else.

Medicare and Medicaid clients require an even tighter deadline of 48 hours

If you're seeing a client through Medicare or Medicaid on Headway, the compliance requirements are more strict, with a tighter deadline of 48 hours after each session.

We’ll note this exception for relevant clients when you’re confirming their sessions.

More resources

You can find a complete list of documentation requirements outlined in Headway’s Provider Policies.

You can also read our compliance guide for a handy overview of documentation, billing and compliance review standards.