Medical Records Documentation
January 18, 2013
HCR / 220
Compliance plans are in place to insure the medical facilities are following any official requirements. Some areas which are included in a compliance plan are staff education and training, early detection of problems in the facility, and avoidance of negative legal actions. The steps in the medical billing process that are covered in a compliance plan are steps five reviewing coding compliance and step six check billing compliance.
Medical records should follow a compliance plan to insure all areas of patient records are complete. Medical records apply to all steps of the billing process. These areas include record accuracy, patient’s condition and diagnoses, the patient’s course of care should be outlined. Medical records must be accurately completed and kept up to date with the patient’s current information. Patient records are private legal documents and in order to avoid any legal actions the compliance plan should be followed.
All steps of the billing process apply to documentations standards and should follow a compliance plan. To insure all patient and facility records follow the set documentation standards employees should be educated in the correct areas of completion of medical and facility records to decrease the case of documentation errors. Employees must follow all documentation standards to ensure correct information is input into patient records which aids in the process of accuracy, etiquette, and customer service. Ensuring all standards and plans are followed allows for lower chances of record error and or medical lawsuits. All steps of the billing process, compliance plans, and documentation standards must be followed in medical facilities.