Awareness : OBC Tips

Tips for Documenting Medical Records

Tips for documenting medical records:

  • Documentation helps to answer these questions:
  • Who? -Who was performing the service?
  • What? -What type of services are performed?
  • How many?-What are the quantities of services performed?
  • Where?-What is the place of service?
  • When?-When is the service date?
  • Why?-Establishing medical necessity and diagnosis