Download Reference Document The terms incident, burst and full episode were coined by us here at KMC University as a way for providers to consider and clearly define the length of an episode of care. When sitting down to document the initial visit of a new episode, consideration of the potential length of the episode…
The Anatomy of a Patient’s Chart
There are many pieces of a patient’s chart, whether paper or electronic. Multiple types of documentation are required for a complete and compliant patient chart. The way the chart or file is organized is critical to proper recordkeeping. Sometimes, we take for granted how simple the chart building process is, or how we use the…
Incident, Burst or Full Episode
Initial Visit Prompts for Providers The terms – incident, burst, and full episode of care – were created to provide a visual image for providers as they begin their clinical decision-making in the care of a patient. Doctors have a fiduciary responsibility to evaluate patients to determine the entire clinical picture. This begins with the…
Checklist for the Use of Medical Scribes
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,…
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…
Documentation and Coding Reference Documents
Download Reference Documents The documents found here are references from the profession that outline standards set for documentation and coding. Download, review and save them, as appropriate for your continued reference. AHIMA Standards of Ethical Coding Sample Medical Review Policy