Are your clinical records good, bad or ugly?
I audit lots and lots of dental records. I like the challenges of auditing detailed records, as I have to pay close attention to identify potential documentation and billing issues. Unfortunately, and all too often, the records I have to audit are not detailed and result in a lot of red ink on my audit reports.
Common charting that I encounter looks like this:
- Comprehensive Exam
- 2 bite wings
- 2 PA’s
- Pulp/SSC #A ,B, D, E, F, J, K, L
- Ext. #C
- Sealants #S, T
- Completed planned TX
- Prescription amox. And T#3
- NV: 6 mo. Recall
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