Serbin Medical Billing: 4 guidelines for medical record documentation

Serbin Medical Billing published guidelines for medical record documentation that apply to medical and surgical services in all settings.

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Here are four guidelines:

  • Ensure services billed are supported by the medical record documentation.
  • Make documentation legible and complete.
  • State the reason for the encounter, or make sure the reason easily observed.
  • Clearly document changes in treatment or diagnosis.

Additional tips can be found here.

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