I just edited my response and attached one that we started with. We took that form and then recreated it in Microsoft Excel and added the things that our organization needs us to also check for. (Some examples of what we added to our form: ICD-10-CM codes the provider coded versus what we coded. Quality measures we have done training on that we want to make sure they are capturing. We also added a section for our observations that we can report back to the provider when we shadow them and meet with them.) That form is nice because it is one page and you can use it as a reference or laminate it and use a write on wipe off pen on it. You could create another side to the form that had other info you need to capture so it would be laminated but 2 sided and have everything you need on it.
Thank you. This is helpful.
