lillianivy
Networker
I need help!!! My doctors need concrete guidelines informing them what documentation is audited. Basically, they are disputing that if a dx is on a lab/rad/other note, but not on that DOS documentation that since it is somewhere else in the chart it's fine. My impression is that only that DOS medical note is what is audited and if it is not documented on that one note then you can't use it. Also, that the results from labs/rad reports reviewed for that visit must be noted on the medical note. Can anyone point me to the specific guidelines regarding this? Or informing me of what documentation is audited. Thanks so much.
Lydia
Lydia