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Wiki Chart Audit of forms completed

Thread starter PennyG
Start date Aug 9, 2013

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PennyG

Networker

Aug 9, 2013

I have a provider who thinks it is appropriate to complete the exam portion of a physical on a form the patient has brought in, say for a college physical, but not dictate the exam. I am telling the provider this is not correct. Will a chart auditor even reference the form if the note only states see physical form? I told the provider the exam must be dictated in to the note.

Any insight on this matter will be greatly appreciated.

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