Medical documentation tips for physicians


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Survive RAC audits, stay in compliance and maintain perfect documentation through these simple tips.

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Medical documentation tips for physicians

  1. 1. Medical documentation tips for physicians MedicalTranscriptionsService
  2. 2. Are you documenting right? Tips to survive RAC audits and reimbursement cuts! • Documenting in today’s healthcare landscape is a unique challenge in itself. Improper documentation and being overly dependent on EHR templates, has snowballed into a huge issue.
  3. 3. Tips to help you beat documentation blues! • Being timely is important. • History and physical notes should be signed within 24 hours of seeing the patient. • Operative notes should be documented and signed within 24 hours of the operation. • Medical records will have to be completed within a week of the patient’s discharge. • Work swiftly to avoid delays that will throw your documentation workflow out of gear.
  4. 4. • Document clearly and don’t skip the details. The more detailed and specific a physician’s documentation is the higher the reimbursement. It can help medical coders freeze on the right codes and improvise on patient care.
  5. 5. • Don’t use EHR shortcuts and pick-lists to document your patient records. Depending completely on them can lead to selective and restricted documentation. Customize your EHRs or use paper charts to record important information.
  6. 6. • Expand your SOAP notes to document more clearly. Add patient quotes and opinions in the Subjective section. Use reproducible and supportive medical data. Document the various treatment options you discussed with patients. This will add more credence and acts as helpful additional documentation while filing claims.
  7. 7. • Hire cross-trained staff. Documentation has become more complex, extensive, detailed and the single most important component across the care continuum. It requires skilled and trained personnel to handle and maintain your practice’s documentation.
  8. 8. • It is healthy practice to start documenting records as quickly as possible. Just a few hastily scribbled notes during the patient encounter can go a long way… Always have a scribble pad in hand to jot down those important details, if you find logging into your EMR every single time frustrating.
  9. 9. • Always cross verify the data inputted into your EMR, spotting discrepancies before they metasize into an enormous problem, is important, especially at a time when medical practitioners are working under intense scrutiny.
  10. 10. • Conduct internal audits regularly. A few sporadic proofing and verifying sessions won’t work. It is the responsibility of physicians to check the medical records for accuracy before signing them.
  11. 11. Thank You…!!! For details Call 877-272-1572 or visit