Wiki Need Guidelines for Filing on Charts

[LLinville]

Help! Yes, we are still using charts. Is there any legal guidelines or standards that should be followed when putting documentaion on charts? Our Physicians are wanting there dictation and reports in a variety of places within the chart. We do have tabs in the charts but they don't like them either. On a auditing note this is a nightmare. I would like something or a website that I can pull to show our physicians that making your coder or auditer crazy is not a good idea. Thanks.

 

[janetmoh]

There needs to be some standardized order. You might be able to find a standardized order somewhere but basically you need to do what will work best for your situation. You might want to point out that not having a standardized order can lead to poor patient care, wasting of time, and ultimately inaccurate reimbursement (if you can't find it, you can't code it!).