Providers should submit adequate documentation to ensure that claims are supported as billed for more information please refer to complying with medical record documentation requirements fact sheet pdf and the cert outreach education task forces webpage. Complying with medical record documentation requirements mln fact sheet page 3 of 7 icn 909160 april 2017 third party additional documentation requests upon request for a review it is the billing providers responsibility to obtain supporting documentation. Documentation of medical records introduction o in a continuous care operation it is critical to document each patients condition and history of care o to ensure the patient receives the best available care the information must be passed among all members of the interdisciplinary team of caregivers. In the legal system documentation is regarded as an essential element extending the risk management dimension failure to document relevant data is itself considered a significant breach of and deviation from the standard of care 1 3 of course protection from legal jeopardy is far from the only reason for documentation in clinical care the patients record provides the only enduring . Consistent current and complete documentation in the medical record is an essential component of quality patient care the following 21 elements reflect a set of commonly accepted standards for medical record documentation an organization may use these elements to develop standards for medical record documentation
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