Medical Records for Accuracy and Completeness

Medical Records for Accuracy and Completeness

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Your job is to analyze medical records for accuracy and completeness. Dr. Jones admits more patients to the hospital than any other surgeon. Repeatedly, you discover that Dr. Jones is adding progress notes after the patient has gone home, because these notes are added while the records are being completed in the department. However, all of the notes are signed and dated as if they were written while the patient was in the hospital. You also know, after reviewing hundreds of medical records, that several physicians add retrospective documentation to the medical record and that some of the retrospective documentation allows these physicians to get more money when they bill for services rendered for hospitalized patients. What are your reporting obligations? Medical Records for Accuracy and Completeness