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There comes a point in the doctor-patient relationship when the doctor has done all they can, and it is in everyone’s best interest to refer a patient out to another provider. Your documentation needs to address the referral process since it is an important part of the patient’s story.

Most providers are unaware of and never look for the red flags in their documentation and coding which could trigger an audit.

SOAP Documentation: Prevent Financial Consequences Many doctors have invested thousands of dollars in an EHR system loaded with templated macros used to create their…

Our recommendation: get proactive, and find out what's really going on in your documentation before an outside auditor does.

As providers create medical records of the encounters between the doctor and the patient, the format for collecting the required information can vary drastically. Practice style, patient population, and personal preference are all considerations when choosing how to gather information from the patient to meet compliance standards.

Successful providers review their coding and documentation and strive to improve accuracy and compliance. Documentation involves far more than just writing down a list of services or copying notes from visit to visit. Likewise, proper coding involves more than just figuring out what codes the payer will accept and billing those.