The main goal of your progress note should be to document your decision-making so that your work can be understood by others, including some one questioning your care in litigation years later. The second goal should be to support your level of coding and billing.

Our templates have concise and relevant information regarding the different conditions being documented. You should always edit the templates in order to document accurately. For some complex patient presentations, it is better to dictate or write the old-fashioned way. Finally, you should always read your notes before you sign them.

Posted on: September 12, 2019, by : admin