Do you know what is (or isn't) in your documentation?

A s you write your progress notes, you probably cannot help thinking of the many audiences you’re serving: yourself, other physicians who may need to consult your notes, the coder and biller who will turn your documentation into claims, and even the auditor or, worse, the plaintiff’s attorney. The last two are just shadowy possibilities, and you already know what you and other physicians are likely to need from your notes. But how good are you at producing documentation that coders need for optimal code selection? As a certified professional coder, I’d like to give you a chance to find out.