The Business of Wound Care

The 3 Critical Components to Improve Documentation on Patient's History

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Documentation on patient's history is usually an area of weakness for many wound care clinics. And it could be a negative finding on an external audit by the OIG. 

Today's episode we have a masterclass taught by Gretchen Dixon, MBA, RN, CCS. Gretchen has vast experience working with clients during OIG audits. In this episode Gretchen teaches the 3 components that are critical to get right when documenting patient's history.

  1. Must establish medical necessity for services in the patient’s History component of the Evaluation/ Management documentation.
  2. Chief Compliant or reason for the visit must be documented in the patient’s own words.
  3. Chief Compliant is Stage 1 of 2 for meeting the requirement of medical necessity for services.

    4. Get all of the resources you need to grow your wound clinic business, visit www.WoundEducationPartners.com 




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    The Business of Wound CareBy Wound Care Education Partners
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