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Monitoring Document Completion

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Last Post by Sara Quaidoo 12 years ago

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abulsara

(@abulsara)

Posts: 150

Estimable Member

Topic starter

I was recently asked to create a report to monitor document completion by my leadership team. I would like to know how other sites are handling this type of request? Basically, we want to know how many documents are missing specific elements of an office visit note that are must haves'. If anyone has anything that they are willing to share, I would really like to hear back from you ([email protected])

Posted : June 6, 2012 7:59 am

eliasp

(@eliasp)

Posts: 18

Eminent Member

Let me guess. The focus is on required bullets for billing and has nothing to do with whether or not there is enough clinical information to support the assessment and plan?

If this is the case, I predict that the providers will perceive it as more punitive than supportive. Based on my experience with similar projects.

Posted : June 6, 2012 8:51 am

abulsara

(@abulsara)

Posts: 150

Estimable Member

Topic starter

I guess it is a little bit of that but I believe it was more so for Meaningful Use and Quality improvement.

Posted : June 6, 2012 10:44 am

Sara Quaidoo

(@sara-quaidoo)

Posts: 3

Active Member

Sounds like concern over integrity of a sound legal medical record, ideally I believe that is part of the activities of your HIM or records management professional.

Posted : June 11, 2012 6:44 am

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