Documentation is important

The Alberta Medical Association (AMA) would like to remind physicians to keep and maintain proper documentation for all patient encounters.

Alberta Health's Program Monitoring and Compliance unit has advised that many physicians undergoing review have inadequate records. The following suggestions should help with this task:

• Buy a small book and pencil, and keep them with you at all times. You can then easily track and record phone calls with various providers. This will also serve as a log for billing purposes.
• Keep track of the times you speak with facility staff (these calls are very often not recorded in the chart at the facility).
• Record every encounter with a patient in the patient’s chart (including visits billed on a cumulative time basis). This way, you will record all callbacks and multiple encounters on the same day, and these will be reflected accurately in the chart if there is an audit or billing review.