Here’s how to improve documentation
November 1, 2001 less than 1 minute read
Here’s how to improve documentation
When it comes proper documentation, here’s what the Bethlehem, PA-based consulting firm of HP3 says are fundamental rules every practice should follow:
- Medical documentation should be complete, clear, and specific.
- The attending physician is the ultimate authority for determining what kind of clinical documentation goes in a patient’s records.
- Physicians should document the rationales behind their treatment decisions. For example, when a test or drug is ordered for a patient, the physician should document the diagnosis or differential diagnoses he or she is treating, confirming, or ruling out.
- Improved documentation is an ongoing process, not a one-time or occasional effort. It must embrace every person involved in the coding and documentation chain, including physicians, case managers, nurse managers, coding professionals, other clinicians, and compliance officers.
Article Limit Reached
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content