Want to help keep your medical office’s documentation crisp, complete and legible? Use this checklist to make sure that your patient files pass muster if an auditor ever comes calling.
PATIENT DOCUMENT CHECKLIST
Before you file away that patient document or send it to an insurance carrier, take a minute to look at the file and ask yourself:
Is the documentation legible?
Does the documentation substantiate the patient service?
Does the documentation clearly identify the provider of the service?
Is the documentation complete and accurate?
Can you read the documentation?
If you can’t answer "yes" to all of these questions, don’t file or mail that document – fix it first!