The Steps for Medical Documentation are patient 1. check-in, 2. insurance eligibility and verification, 3. the coding of diagnosis and procedures, 4. charge entry, 5. claim submission, and finally 6. payment posting.
Medical Documentation is required because with out the documentation, patients can be miss diagnosed, or malpractice can occur. If something went wrong during a procedure then the doctors or attorneys can refer back to the medical documentation to see what went wrong on what day and what time the patient was seen.
Principles of Documentation
1.The medical record has to be complete and legible.
2.The documentation of each patient encounter should include:
·reason for the encounter and relevant history, physical examination
Medical Documentation is required because with out the documentation, patients can be miss diagnosed, or malpractice can occur. If something went wrong during a procedure then the doctors or attorneys can refer back to the medical documentation to see what went wrong on what day and what time the patient was seen.
Principles of Documentation
1.The medical record has to be complete and legible.
2.The documentation of each patient encounter should include:
·reason for the encounter and relevant history, physical examination