Medical Documentation Research Paper
The steps in the medical documentation process are:
Register the patient.
Use patient insurance information to verify eligibility.
Establish patient financial responsibility post payment
Code for services rendered submit claim check out patient continue to follow up with patient until patient is healthy
The reason why medical documentation is required is because it is Important to keep track of the patient and their health status. Not to mention having medical documentation serves the purpose of billing insurance and medical liability.
List the principles of documentation:
Always document date and time
Make sure handwriting is legible
Use correct spelling
Use only black or blue ink
Use correct terminology include FACTUAL evidence
Be accurate
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