Documentation & Coding Archives

Best Practices for Timely Documentation

Some providers think of documentation as a drudgery. An endless pile of work with no end in sight. However, there are rules that govern when documentation must be completed. Let’s start this module with an overview to go full circle into the need and definition of contemporaneous documentation of patient health record notes, their completion…

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Amendments-Corrections-Delayed Entries

Download Reference Documents Medicare understands, Chiropractors can be wonderfully effective providers, yet they often make unforced errors in the documentation like other doctors do. Also, it’s clear that providers may become aware of pertinent patient information needed to add to a completed note. This Reference Document is Medicare’s own Change Request document that outlines exactly…

Amending the Patient’s Record

Sometimes, “Adjustments” are Necessary 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 may be considered fraudulent. CMS has direct guidance…

Timely Documentation in Day 1.5

The “Day One and a Half” System Consistent, installed systems bring consistent practice success. “Day One and a Half” is a critical system. To be successful, create regular time to manage this pivotal, timely documentation process. We suggest that each shift makes time for this all-important activity at least once a day. Initial visit and…

Timely Documentation Hints and Helps

Timely Documentation Hints and Helps The love of seeing patients, whether routine or new patient visits, is often overridden by the task of documenting the visit. Each may require different amounts of detail and time for documentation completion. This quick mini class provides real life examples and the consequences of poor adherence to the timely…

Timely Documentation Best Practice

Documentation is Part of Your Treatment It’s easy to get busy in a practice, not just with patients, but with the seemingly never-ending paperwork. As frustrating as it may be, it’s a part of the treatment to document the visit. We suggest that you consider setting your own practice standards for documentation timeliness in your…