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Unformatted text preview: be exact, encompass the patient’s diagnosis and all information pertaining to the condition, and the course of care is being provided. These documents are legal documents and must always be precise. These documents may be used by a physician or facility if legal action is pursued. Documentation Standards Because of the 10 steps connected to compliance plans, documentation standards, and medical records compliance plans correlate with documentation standards. Connected with compliance plans are the verification of compliance in billing and coding. Included in the correlation would be anything pertaining to patient information or the documentation of any type. Documentation standards include all patient statements, preparation of the claims, the transmitting of those claims; follow up of payments, and monitoring of payer adjudication....
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- Winter '11
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