Wiki Medical Record Notes vs test not performed

YES!!!!! The medical record is a legal document and must always be correct. The coding and the claim is based on this documentation. How can you have a procedure note dictated yet no procedure performed??? Serious stuff. A note for what was done cannot possibly be created until the procedure is done. You see what I mean, every patient is different so every procedure note will be slightly different. The claim must be created based on the documentation, the patient can contest and now you have a problem
Just a question that student asked...not real scenero.

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