Download Reference Documents Here we provide a sample from the Colorado State Board that provides the record-keeping requirements (including the minimum documentation expectations) for this state for both Initial and established patient visits. This resource is an example of similar resources that should be available in each state. We recommend that you locate and become…
Anatomy of Routine Office Visit (ROV) Documentation Samples
Download Reference Documents These documentation samples are provided not only as examples of the necessary components of a note but also to indicate in the sidebar the reasoning for the individual pieces needed to create the best possible note to document and relay the information essential for various patient case types. Notice that the look…
Initial Visit Documentation Reference Documents
Download Reference Documents These Reference Documents are helpful tools as you continue to get familiar with and follow the rules of documentation of initial visits. First, you’ll find the official document from the American Medical Association (AMA) laying out the new 2021 Evaluation and Management (E/M) updated guidelines for coding your E/M services. This document…