Documentation If it is not legible and complete YOU cannot get paid!

Having legible notes, supporting documentation, and signatures are important to all parties involved and important in order to avoid denials.

Medical records should be:

  1. Complete and legible.  
  2. Should include the legible identity of the provider.
  3. The date of service.
  4. Any amendments, corrections, or delayed entries must clearly and permanently be identified, clearly indicate date and author, and clearly identify all original content.
  5. Must contain signatures.
  6. Signatures must be clear and legible (use attestation statements or signature logs).
  7. Illegible documentation can have the physician’s staff transcribe it and have physician confirm it is a true and correct translation.
  8. If documentation is not legible and correct what should be done:

a.    Explain to patient it is not covered without correct and legible documentation

b.    Get the patient involved

c.    Use an ABN if patient still insists and do non-assigned with the ABN

REMEMBER:  If it is not documented it is not covered. 

Use the US Rehab/VGM audit help site or for additional assistance contact:

800-401-3643   Peggy Walker, RN in South Carolina

888 665 6518   Ronda Buhrmester, CRT, CFm in Iowa