BC Advantage - 2012 Issue 7

Documentation and the Scribe

By Kathy YoungRecently I traveled out of state to visit a new client, to discuss their documentation with them so that I could help and train them on being more successful.  It was during one of my interviews with the Provider's scribe that I discovered some alarming practices that would need to be addressed.  I asked the scribe to walk me through an encounter from beginning to end.  She showed me how she asks the patient the questions for the review of systems.  She then showed me the paperwork the patient brings in and how...

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