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Date: July 15,2026
How to Document Late Entries in the Medical Record
Occasionally, therapists and assistants may forget to document a note in the medical record. This could be a daily note, progress report, or discharge report. When this occurs, what is the correct process for documenting and dating late medical record entries?
The Centers for Medicare and Medicaid Services (CMS) states the following:
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Rick,
If a physician refers a patient to PT in Massachusetts, how long is that referral valid for? Can they start PT a few months later? Also, is there anything specific to referral duration for a Medicare referral to PT now that we don’t have to have the Eval POC signed but just proof of sending it?
Thank you for the help. Great Webinar last week too!
Keith Linsey
You would need to check your Massachusetts therapy practice act and any other administrative rules that apply to you.