14 min
The 3 Critical Components to Improve Documentation on Patient's History The Business of Wound Care
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- Medicine
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.
Get all of the resources you need to grow your wound clinic business, visit www.WoundEducationPartners.com
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.
Get all of the resources you need to grow your wound clinic business, visit www.WoundEducationPartners.com
14 min