Download Support Tool One of the most effective ways to ensure compliance is to perform periodic self-audits. These important self-checks are even a requirement of an office compliance program. By performing a retrospective review of a sampling of signed visits, you will establish a baseline of your current compliance with the signature guidelines. Download, review…
One of the most important elements of a complete medical record is the name and signature of the provider of service on each date of service. Medicare has set the standard for all payers on what is required to confirm the medical record and validate who provided the service. Most other payers follow the same…
Paperwork Folders In an efficient office, there is a system and procedure for everything. This makes training for team members easier and downtime or non-patient-related time more effective. Do you find yourself “scrounging” to find patient paperwork each time a new patient walks in the door? While this may be frustrating for you, imagine how…
Download Reference Documents Every provider didn’t dive into the Electronic Health Record (EHR) revolution. Some have remained with the familiar paper chart of documentation, and some use a hybrid. Download and review this helpful comparison document to evaluate the pros and cons of each, as you determine whether your current system is serving you and…
The Health Record Asset We’ve all heard the adage, “If it wasn’t written down, it didn’t happen.” Encounters between doctors and patients are “written down” in the patient’s health record. That record is one of the most important assets owned by the practice. It is the final, legal document that describes the conditions and treatment…
Download Support Tool Here is a list of abbreviations to print out and utilize when documenting in the patient’s medical record. Health care has many standard abbreviations that are consistent throughout the country and even worldwide. No matter where you go in the United States, BP stands for blood pressure, C/S stands for cervical (spine),…