Survey Scoop: G-236 Clinical Records

What will the surveyors expect?

What a huge topic! The best strategy to ensure compliance with this standard is to become familiar with your policies on clinical documentation, authentication and corrections.

When a surveyor asks you how many days are allowed to incorporate a visit note into the medical record, what is your response? Don’t guess and don’t try to impress the surveyor by quoting a stricter standard than the policy. Once you quote a standard to the surveyor, you will be held to that standard.

Check the policy and, if you’re still not certain or if you can’t find the policy, call (800) 447-5464 and ask to speak to Lori Velko, Patti Davis or Terry Greene. We will be happy to coach you through your survey.

Surveys are stressful and the results reflect on all of us! We are here to help you demonstrate how you are improving the lives of our patients every day.

Note submitted by: Lori Velko, Director of Compliance

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