Optimizing reimbursement: Tips and tools
Rehab Regs, February 6, 2009
The medical record should only contain objective, factual information that pertains to the direct care of the patient. Entries in the medical record should include:
- Only the facts
- Objective data without opinion or assumptions
- Physical evaluation details
- Details of conversations with patients, family members, and other healthcare providers
- Actions taken to care for patients
- Details of conversations with the physician and documentation of his or her orders or directives
- Implementation of the physicians' orders or directives
This tip is from HCPro’s Pocket Guide to Therapy Documentation.
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