Primary Care Coding Alert

Clarifying documentation can be a big help -- if used wisely.A long list of government entities pore over your patient records, but that doesn't mean you have to be a helpless target. Follow these tips about documenting corrections and additions to your physician's notes to help avoid red flags. Yes, You Can Correct On Behalf of OthersStaff sometimes question whether they are allowed to make corrections to a medical record if someone else (i.e., a supervisor) asks them to do so.The answer: It is perfectly OK for a clinician to make changes to the record at another person's request, says consultant Judy Adams in Chapel Hill, N.C. Be sure the physician actually remembers the information, or reads notes or other written information that triggers their memory of the additional information, adds Washington, D.C.-based attorney Elizabeth Hogue.Judge Whether Clarifications Are Too LateWhether your correction or late entry is helpful or harmful may [...]