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Doc/Coding tips

The Importance of Data Agreement within the Medical Record
Posted: June 5, 2018

3rd party audits will often explore specific parts of the medical record looking for disagreements in documentation.  As an example of such a disagreement, consider a past medical history and ROS showing all systems to be “negative” while the active medication and/or problem lists suggest otherwise.  Or a past ocular history as “negative” despite cataract surgery being documented elsewhere in the record.

It’s easy to look at these in isolation and say, “that’s no big deal”.  And honestly, a 3rd party might do just that.  However, the more instances of these disagreements found in an audit, the more the auditor will begin to question the quality of the provider’s documentation and also if the auto-populate (i.e. default “normal” button) feature was used without review.

It’s best to avoid those questions completely by making sure that all elements of the record are in agreement prior to signing the encounter.





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