Try showing this to your provider:
To ensure that medical record documentation is accurate, the following principles should be followed:
The medical record should be complete and legible.
The documentation of each patient encounter should include:
o Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results.
o Assessment, clinical impression, or diagnosis.
o Medical plan of care.
o Date and legible identity of the observer.
I found this at http://www.cms.hhs.gov/MLNProducts/d...serv_guide.pdf
As I often see here: kick him in the bucks.
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