Medical Records:
Keep the 'Five W's' in Mind for Exceptional Documentation
Published on Fri Mar 09, 2012
Pay close attention to the ideal 'who' listing for your records.Most of us are familiar with the bare minimum requirements necessary for medical documentation -- but how many practitioners can say that their documentation is "exceptional"?TrailBlazer Medicare's Sherrie Varner answered the question about how to create exceptional documentation during the MAC's Feb. 8 webinar, "Medicare Documentation and Audits." Read on for her tips about the "Five W's" that make medical records shine.Who. List the performing, supervising, and referring practitioners.What (and how many). Document the services and quantities of services performed.Where. The place of service.When. The date of service. Why. "This is the one where we frequently find more problems, making sure that practitioners are documenting medical necessity and the diagnosis," Varner said."We want you to paint us a picture," Varner said. "You know what's happening with your patient, but that information has to be communicated from your head into the documentation [...]