Amending the Medical Record Despite best efforts and good intentions for perfect documentation at the time of service, errors and omissions occur. When that happens, the situation has its own documentation requirements. Failure to properly amend the medical record may give the appearance of falsifying documentation, which is considered fraudulent. CMS has direct guidance for…
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Sometimes in our busy day-to-day life, patients don’t remember the details of their health record. This is one reason for the portability of health records…to be able to glean information from provider to provider in an effort to have the most complete health record. What if the patient failed to mention something? What now? Don’t…
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Download Reference Documents As practices grow and expand, the pace in the office increases. You may find that just keeping up with the basic paperwork requirements to keep you compliant are eroding the time you can spend with your patients. To take some of the burden off the provider and still get the work done,…
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Pros and Cons of Using a Scribe The practice of using a scribe is as ancient as the practice of medicine itself. Priests, politicians, physicians, and scholars have long taken advantage of using another person to write down their thoughts and actions. This guide outlines ideology, guidelines, and other considerations for using a clinical scribe….
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Guidelines For Scribes Medical practices using Electronic health records (EHRs) have increased their use of scribes. Medical and nursing students make good scribes because of their knowledge of anatomy and medical terminology, but there are no training or certification requirements to become a scribe. The Joint Commission, which accredits and certifies healthcare organizations and programs,…
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Using a Scribe in Your Office Chiropractic practices have increasingly turned to scribe assistants as they search for ways to streamline the documentation process and improve overall productivity. Scribes are not medical providers (although some may have medical backgrounds) and they don’t treat patients. A scribe’s main task is to document in the patient’s medical…
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