Wiki examples of wrong medical documentation?

[CodingMari]

Hi Everyone,


lately I have been utilizing the forum to try an find some rhyme and reason to level out charts that are poorly documented.

I have been given an opportunity to work for a private practice and love to educate the providers on poor documentations. But I don't even know where to begin!

HELP!!

 

[erjones147]

Start with the elements of a proper HPI. Let the providers know how much proper duration, severity, etc. is appreciated by the coder