• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
  • Important Note: We will be performing a scheduled maintenance on 1st November 2020. The site will be offline from 7:30PM (MT) till midnight. We apologize for any inconvenience this may cause.

Physician sees patient and doesn't dictate office note, ok or not?

Messages
36
Best answers
0
We have a physician who saw a patient but doesn't have a dictate note for the visit. We are not sending the charge through but is it even ok to not have documentation for this? Advice please!
 

CatLaw

Guest
Messages
51
Best answers
0
I have seen where patients want to self pay and not send to insurance for personal reasons, and request not to have a record kept. But it is always best to keep records of everything in case an issue were to come up, such as malpractice suites. If you don't have record to back yourself up, that doesn't look good. I recently saw a physician that lost his license because he did not keep accurate records. It would be in your best interest to have the physician dictate a note.
 
Top