Effective Auditing of Physicians' Notes
Gain an understanding of audit factors that are most important, and what to do if the audit yields a bad result. Auditing provider clinical records (i.e, the visit note) is a critical part of building a strong compliance program that defines what is needed in producing a high quality meaningful note. The days of creating three-page clinical notes with useless information are gone. The note must be the focus and deliver the critical information others need to care for the patient. The clinical record needs to mirror the level of coding within the requirements of the American Medical Association Evaluation and Management coding requirements. Three to five-page notes are no longer needed. Learn to effectively audit the provider clinical note and stay in compliance.
Who should attend?
- Medical Necessity
- The Reason Why
- CMS RulesWhat Are Auditors Looking for?
- Why Is the Patient Here? The History of Present Illness HPI
- What Is the Subjective Presentation? The Review of Systems (ROS)Meaningful Note
- The Subjective, ROS, HPI and History, Objective, the Exam, the Assessment and Plan (i.e., the Soap Format of Documentation)
- The Abomination of the Meaningless Redundant NoteAudit the Note
- Audit Forms
- CMS Audit ToolsCompliance as a Part of the Audit Process
- Audit Compliance
- Education of the ProviderPhysician Extender Clinical Notes
- State Requirements for Supervising Physician Extenders
- The Collaborative Practice AgreementInsurance Company Request for Records
- The Importance of the Practice Auditor to Review the Records Before They Are Sent
- Does the Billing Office and the Provider Have Knowledge of These Requests for Medical Records?
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