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Wiki Correcting Documentation

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257
Location
Tampa, FL
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What is the correct way to correct documentation in the following scenarios?

Scenario one - Provider has NOT signed off on notes and left out the words "1.5cm" so there is no mention of the size of the lesion that was treated.


Scenario two - Provider HAS already signed off on the note and left out the words "1.5cm" so there is no mention of the size of the lesion that was treated.


Assume he/she wrote the information on the fee ticket, but not the medical record.
 
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