AprilSueMadison
Expert
What is the correct way to correct documentation in the following scenarios?
Scenario one - Provider has NOT signed off on notes and left out the words "1.5cm" so there is no mention of the size of the lesion that was treated.
Scenario two - Provider HAS already signed off on the note and left out the words "1.5cm" so there is no mention of the size of the lesion that was treated.
Assume he/she wrote the information on the fee ticket, but not the medical record.
Scenario one - Provider has NOT signed off on notes and left out the words "1.5cm" so there is no mention of the size of the lesion that was treated.
Scenario two - Provider HAS already signed off on the note and left out the words "1.5cm" so there is no mention of the size of the lesion that was treated.
Assume he/she wrote the information on the fee ticket, but not the medical record.