Although it may be annoying to document all of the details required in an initial visit or daily note, there are good reasons to embrace this aspect of your practice.
Your documentation must:
- Demonstrate medical necessity
- Create a complete record of a patient's treatment
- Provide a way to communicate with other health care providers
- Record pertinent facts, observations about a patient's health history (past and present), examinations, diagnostic tests, treatments and outcomes
- Provide a chronological recording of a patient's care
Does your documentation system make it easy to complete all of these compulsory items?
Proper documentation establishes a chronological record of exams, tests and results, treatment, and treatment plans, including the diagnosis and prognosis of the illness or disease. Something you are obligated to do, even if you run a cash practice.
If you're still using a multi-visit travel card, you're probably not collecting the necessary information. Do you get medical necessity denials? Then you're probably not recording the necessary information. Nervous about a post review audit? Then you already know your documentation could use an upgrade.
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