Document Accuracy Checklist

Medical Office Front Desk Pro 2009

Ensure patient docs are legible, complete.

Want to help keep your medical office's documentation crisp, complete and legible? Use this checklist to make sure that your patient files pass muster if an auditor ever comes calling.

Tips come courtesy of Susan Manning, JD, of Wisconsin, who presented this information at an American Association of Professional Coders conference.

PATIENT DOCUMENT CHECKLIST

Before you file away that patient document or send it to an insurance carrier, take a minute to look at the file and ask yourself:

Is the documentation legible?

Does the documentation substantiate the patient service?

Does the documentation clearly identify the provider of the service?

Is the documentation complete and accurate?

Can you read the documentation?

If you can't answer "yes" to all of these questions, don't file or mail that document — fix it first!