Documentation Introduction
From Guide to YKHC Medical Practices
It is very important that you have good documentation so that the providers coming after you can see your plan for the patient. Your clinical supervisor will review your records quarterly. The coders will also be reviewing your charts and asking for more documentation if necessary.
Some important points to remember:
- Choose the correct note type.
- Type as much as you can during the visit.
- Always do the Depart/Discharge Summary
- Meaningful Use Requirements:
- Patient education
- Follow up
- Medicine Reconciliation
- Meaningful Use Requirements:
- Any time you perform an action for a patient, e.g., follow up on a medication, review labs, etc., please document what your plan is in an addendum, a free text note, or a general message saved to the chart. This way subsequent providers can see your action and plan.
- Letters sent to the patient via PowerChart/FirstNet are also saved under ‘Documentation’ and can be used to explain to later providers what happened.
