Well, though I'm sure you pride yourself on your recall systems, documentation, audit proof EMR's, and lab follow-up processes, despite the best of intentions, things will slip through the cracks. So if you are worried, and you should be, do an internal audit before someone else does it. You'll be surprised at what you find.
- Do your consults have associated referral letters
- Do your no-shows have documentation regarding attempts to contact them
- Are all the ordered labs and studies in the charts
- Are certified letter documents in the charts
- Do all encounters have written notes
- Are informed consent discussions documented
- Are phone conversations documented
- Are all email communications saved in the chart
- Does the documentation fit the coding level
I know that good EMRs can do lots of this for you, but I still believe that random audits are warranted. We do them and find things frequently. I recommend it.
The IU.
