Wiki post- op and dressing changes

[staceymd28]

Can anyone tell me where I can find written documentation that states that if a patient comes in for a post op visit or a dressing change that a medical note must be done in the patients chart. I have one doctor that does and one that doesnt seem to think it is necessary. As a biller I go by if it is not documented then it did not happen. This doctor however is only going to believe me if i have written proof.

 

[JMeggett]

Can anyone tell me where I can find written documentation that states that if a patient comes in for a post op visit or a dressing change that a medical note must be done in the patients chart. I have one doctor that does and one that doesnt seem to think it is necessary. As a biller I go by if it is not documented then it did not happen. This doctor however is only going to believe me if i have written proof.

Hmm, I'm not sure if this is a "rule" or where to find that this "has to be done"...it's just good medical mal-practice rule of thumb to protect ourselves thing to do. What if the patient complains somewhere that something happened while they were in your office on a particular day and you have NO record of patient ever being there or what was actually said to patient? I wonder if your practice has an Attorney that could "advise" the protesting Provider? Sorry, not much help.

Jenna