Wiki In-office Procedure Documentation

[KoBee]

Does anyone have a source where it speaks about the importance of detail documentation needed for in office procedures. We work with some providers who don't write detail procedure notes and seems insufficient.

Example of a note:

Disc. Options. Cort inject given deq. Instruc. Fu prn.

is that enough? is that sufficient?

 

[SharonCollachi]

My source is always the Medical Board of my state. I regularly review what they are criticizing doctors for, and medical records is a big one. You could also check with your malpractice carrier.