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…
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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…
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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…
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