An independent medical record review should be performed at least twice a year to identify coding and documentation errors.
Explanation:
The medical record is a document prepared by the professional and is a fundamental tool for their work. It contains, in an organized and concise manner, all data related to the patient, such as family history, history, description and evolution of symptoms and examinations, as well as indications of treatments and prescriptions. Done in the office or hospital, the chart is made up of valuable information for both the patient and the doctor himself. Its main purpose is to facilitate patient care. This chart should be reviewed at least twice a year to avoid errors that could compromise the client's care and/or treatment.
