Running Head:MILESTONE ONE
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MilestoneOne Draftof – Evaluation
HIM360
SouthernNewHampshire University
January 27,2022
MILESTONEONE
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Maintaining accurate and comple medical records imperative for the success of te is
healthcare organizations. The lack of accurate and comple medical records can affect the te
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. medical record audit must be performed ensure that providers are A to
accurately following documentation procedures.The audit help locating documentation- can in
related weaknesses and help healthcare organizations ascertain the educational needs to of the
providers.
An annual audit was conducted 2019 part Southern New Hampshire in as a of
University’s ‘Family Claims.’ coding compliance process relating to Practice Charges Every
provider previous 90 days encounter was used create table. Then ten random charts per’s to a
provider were chosen using the evaluation and management codes relating new and by to
existing patient office visits. was followed by copying printing of the medical It or
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 were
