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Ultimately Schmitz says that the golden rule for medical records is If it's not documented, it didn't happen. So remember to be smart about meeting requirements and creating documentation that works for your patients, staff, and payers.
What is the most common method used to organize a new paper medical record for a patient? Most medical offices use source- oriented format to organize their medical records, the alphabetic filing system to arrange records and shelf filing units to store the medical records.
If the patient wrote a personal letter requesting records, make sure the following patient information was in the original request:Date of birth.Name.Social Security number.Contact information (address and phone number)Email address.Dates of service and specific records requested (tests, discharge notes, etc.)More items...
Remember the Golden Rule: If it isn't documented, then it wasn't performed. Reviewers do not know the services provided if there is no documentation. You are paid for what you document, not what you did.
To be valid, an authorization form used by health care providers, HMOs and health care contractors must: Be handwritten by you (or your authorized representative signing the authorization form) or be typewritten in no smaller than 8-point type.