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Need Guidelines for Filing on Charts

  1. #1
    St Joseph
    Default Need Guidelines for Filing on Charts
    Medical Coding Books
    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.

  2. Default
    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!).

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