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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!
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.