# Medical Record Notes vs test not performed



## Rip (Apr 27, 2012)

*.*

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## mitchellde (Apr 27, 2012)

YES!!!!!  The medical record is a legal document and must always be correct.  The coding and the claim is based on this documentation.  How can you have a procedure note dictated yet no procedure performed???  Serious stuff.  A note for what was done cannot possibly be created until the procedure is done.  You see what I mean, every patient is different so every procedure note will be slightly different.  The claim must be created based on the documentation, the patient can contest and now you have a problem


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## Rip (Apr 27, 2012)

Just a question that student asked...not real scenero.

Thanks.


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## mitchellde (Apr 27, 2012)

My answer still stands for a hypothetical scenario.  I did not mean to imply that you were commiting a wrong doing.  My apologies!


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