Banner
  • Industry News
  • Access and Reimbursement
  • Law & Malpractice
  • Coding & Documentation
  • Practice Management
  • Finance
  • Technology
  • Patient Engagement & Communications
  • Billing & Collections
  • Staffing & Salary

Practice tip of the week: How to ensure documentation accuracy

Feature
Article

Your weekly dose of wisdom from the Physicians Practice experts.

lightbulb doodle © Matias - stock.adobe.com

lightbulb doodle © Matias - stock.adobe.com

With all the useful information available on Physicians Practice, it is easy to become overwhelmed.

With this in mind, the tip of the week is a chance to reflect on some of the wisdom found all across the site. In the April 2021 slideshow on how to ensure documentation accuracy, Jennifer Frank, MD writes the following:

It's so easy to document much more than we actually did. It is also incredibly easy to document a normal exam as part of a default template. However, these acts of inclusion and omission represent a significant threat to patient safety as well as a challenge to our professional integrity as physicians.

1). Never ever use a copy forwarded note - It just begs to be wrong. It is so easy to pull in a ton of information that was accurate three months ago but which is no longer true. Are you really going to carefully edit that content to make sure it is accurate?

2). Do not use an exam template defaulted to normal - Put stops in the template function that force you to take some action to demonstrate that you stopped and reviewed the exam. If you do use a template, think carefully about what you auto select.

3). If something is abnormal, stop and document it - Jot a quick note to yourself or type in the abnormal exam into the computer. It only takes a moment and improves the likelihood that you will accurately capture the exam.

Click here to read the rest of the article and be sure to check back next week for another Tip of the Week!

Related Videos
Physicians Practice | © MJH LifeSciences
The importance of vaccination
The fear of inflation and recession
Protecting your practice
Protecting your home, business while on vacation
Protecting your assets during the 100 deadly days
Payment issues on the horizon
The future of Medicare payments
MGMA comments on automation of prior authorizations
The burden of prior authorizations
Related Content
© 2024 MJH Life Sciences

All rights reserved.