Running Head: MILESTONE ONE
1
Milestone One – Draft of Evaluation
HIM360
Southern New Hampshire University
January 27,2022
MILESTONE ONE
2
Maintaining accurate and comple medical records imperative for the success te is of
healthcare organizations. The lack of accurate and comple medical records affect the te can
organization’s ability meet the necessary standards and regulations, hamper patient care to as
well satisfaction level, and lead poor financial performance (Giannangelo, 2019). as to
Comprehensive documentation ensures that medical records aid billing payers for the in to
services provided. A medical record audit must be performed ensure that providers are to
accurately following documentation procedures. The audit help locating can in
documentation-related weaknesses and help healthcare organizations ascertain the to
educational needs of the providers.
An annual audit was conducted 2019 a part of Southern New Hampshire in as
University’s coding compliance process relating Practice Charges Every to ‘Family Claims.’
provider previous 90 days encounter was used create a table. Then random charts per’s to ten
provider were chosen using the evaluation and management codes relating new and by to
existing patient office visits. was followed by copying or printing of the medical It
documentation on these charts which were sent the auditor for evaluation purposes. The to
exceptions located during the audit process were captured a spreadsheet. the summary in In
section of the spreadsheet, the charts that did not meet the necessary documentation level
