Chart Closure Policy - Associate Physicians and Non-Physician Providers

Chart Closure Policy - Associate Physicians and Non-Physician Providers

Company: Together Women's HealthDepartment: All
Title: Chart Closure - Associate Docs & APPsP&P#: 
Approval Date: April 2026Review Frequency: Annual
Effective Date: April 2026Category: 
Last Reviewed Date: April 2026Last Reviewed By: CMO, Operations, PAB, & PMD

PUPROSE & SCOPE

Timely and accurate documentation is critical for ensuring continuity of care, regulatory compliance, and efficient practice operations. This policy is designed to ensure compliance with all applicable federal and state laws, regulations, and company and practice policies and procedures related to the maintenance and security of patient health information, including but not limited to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Health Information Technology for Economic and Clinical Health (“HITECH”) Act, and in accordance to the provider’s Employment Agreement.

APPLICABLE INDIVIDUALS

This protocol establishes clear expectations for all Associate Physicians and Non-Physician Providers including Advanced Practice Providers (“APPs”), and midwives regarding the closure of patient encounters, review and sign-off of lab results, and responses to patient cases (e.g. lab requests, prescription (“Rx”) refills, portal and phone messages). Consistent adherence to these guidelines is essential to maintaining high-quality patient care, reducing clinical risks, and optimizing workflow efficiency.

POLICY REQUIREMENTS

Appropriate documentation and chart closure includes, but is not limited to, documenting visit notes, assessment, services rendered, proper coding, sign-off of labs and visit, and response to patient cases (e.g. lab requests, Rx refills, portal and phone messages).

Patient Visit Encounter Closure

  1. All patient encounters must be completed, documented, and closed within 24 hours of the visit.
  2. Incomplete or delayed encounter closures can result in disruptions in patient care, billing inefficiencies, and compliance risks.
  3. Complete documentation includes a detailed assessment and plan. 

Lab Sign-Off

  1. Providers must review, sign off, and take necessary actions on all lab results within seven (7) days from the date it is sent to the provider.
  2. Any abnormal or critical lab findings must be addressed promptly and documented appropriately.
  3. Phone call communication must be documented in the patient’s chart.

Patient Case Response

  1. Providers must respond to open patient cases within 24 to 48 hours of initiation, ensuring that patients receive timely follow-up and appropriate care.
  2. Delays in addressing patient concerns can result in adverse health outcomes and impact patient satisfaction.
  3. Documentation of all communications and actions taken must be included in the patient’s chart.

Monitoring and Reporting 

  1. A weekly compliance report is generated and distributed to all providers at the beginning of the week.
  2. Providers are responsible for reviewing their compliance status and taking immediate corrective actions, as needed.

Escalation and Accountability

  1. Initial Notification
    1. If a provider has more than 10 open encounters, an initial compliance notification will be sent to the provider, via an email to the provider’s work email sent from the Regional Director (“RD”), with a copy to the Practice Manager (“PM”) and Practice Medical Director (“PMD”).
    2. The provider must address outstanding items within one week of receiving the notification.
  2. Compliance Deadline and Escalation
    1. If the provider takes no action to resolve all open encounters identified in the initial compliance notification within one week from receiving the notification, unless an extenuating circumstance is identified (as defined in the “Exceptions and Provider Responsibility” section below), the issue will be escalated to the Chief Medical Officer (“CMO”) and RD for further review.
  3. Performance Plan and Consequences. Failure to comply with the requirements outlined in this policy may result in progressive disciplinary actions. The specific consequences will be determined on a case-by-case basis, taking into account the frequency and severity of the non-compliance, as well as any extenuating circumstances. Possible consequences include but are not limited to:
    1. Placement on a remediation plan in collaboration with the CMO, RD, and practice leadership.
    2. Formal written warnings regarding non-compliance.
    3. Other measures as defined in the provider’s employment agreement up to and including termination of employment.
    4. Further administrative actions as deemed necessary by senior leadership and in accordance with the provider’s employment agreement.

Exceptions and Provider Responsibility

  1. Providers experiencing extenuating circumstances (e.g. approved leave, system outages, extraordinary clinical workload) must proactively communicate with their PM or PMD to request an extension or assistance by other providers in practice.
  2. The above should be documented by PM or PMD and cc’d to RD.

Acknowledgement

All providers must review this protocol. Compliance with these expectations is a condition of continued employment and critical to maintaining a high standard of patient care and practice efficiency.


    RELEVANT REGULATIONS

    Health Insurance Portability and Accountability Act of 1996 (HIPAA)
    Health Information Technology for Economic and Clinical Health (“HITECH”) Act

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