The 3 Critical Components to Improve Documentation on Patient's History

16/02/2021 14 min Temporada 1 Episodio 3

Listen "The 3 Critical Components to Improve Documentation on Patient's History"

Episode Synopsis

Documentation on patient's history is usually an area of weakness for many wound care clinics. And it could be a negative finding on an external audit by the OIG. 
Today's episode we have a masterclass taught by Gretchen Dixon, MBA, RN, CCS. Gretchen has vast experience working with clients during OIG audits. In this episode Gretchen teaches the 3 components that are critical to get right when documenting patient's history.

Must establish medical necessity for services in the patient’s History component of the Evaluation/ Management documentation.
Chief Compliant or reason for the visit must be documented in the patient’s own words.
Chief Compliant is Stage 1 of 2 for meeting the requirement of medical necessity for services.

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