Describe three essential guidelines for charting in a medical record and give one example of a...

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Medical Sciences

Describe three essential guidelines for charting in a medicalrecord and give one example of a legal implication if theseguidelines are not followed.

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Reason for encounter relevant history findings test results and date of service Assessment and impression of diagnosis Plan of care with date and legible identity of observer Incomplete or illegible records can result in denial of payment for services billed to Medicare In order for a claim for Medicare benefits to be valid there must be sufficient documentation in the providers or hospitals records to verify the services performed were reasonable and necessary and required the level of care billed If there is no or insufficient documentation then there is no justification for the services or level of care billed Additionally if there is insufficient documentation on the claims that have already been adjudicated by Medicare reimbursement may be considered an overpayment and the funds can be partially or fully recovered Medical records should be complete legible and include the following information Reason for encounter relevant history findings test See Answer

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