November 2012

November 2012

Having a set of general documentation principles provides a guideline for your practice. Adherence to these principles mitigates risk and ensures conformity across the various types of office forms and procedures.

Here are some recommended documentation principles:

  • Document a patient's progress, response to and changes in treatment and any revision to the working diagnosis
  • Physical examination findings, tests and measurements
  • Identify any health risk factors
  • Make sure that the CPT or ICD-9-CM codes you use on third-party payer claim forms or patient billing statements are documented in the patient's medical record
  • Write neatly and legibly, making sure the medical record is complete
  • Authenticate that the services recorded were delivered with a hand written or electronic signature. Stamp signatures are not acceptable.
  • Document the reason(s) for ordering diagnostic or other ancillary services, or make sure your rationale is easily inferred from the record
  • Ensure that all past and present diagnoses are accessible to a patient's treating and/or consulting physician

Making your documentation fully compliant is one of those "important but not urgent" tasks. (Until an audit!) With the New Year approaching this is the perfect time to give it your attention. Check out for ways to streamline and simplify your documentation for peace of mind and improved reimbursement.

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