Explains the principles of medical record documentation and instructions on how to conduct a medical record audit in the physician's or outpatient office. This resource teaches the reader to review documentation basics and format chart notes. It gives guidelines and elements required for each level of service.

The new edition of "Medical Record Auditor" expands on the first edition's foundation on the principles of medical record documentation and instructions on how to conduct a medical record audit in the physician's or outpatient office. This resource teaches the reader to review documentation basics and format chart notes, and gives guidelines and elements required for each level of service. Tools are provided to aid in properly auditing medical records, as well as instruction on analyzing and reporting results of an audit. Application exercises and a final examination are included to test the reader's comprehension of the material.This title includes new features such as: a CD-ROM containing all of the answers to the exercises, audit tools and report templates, auditing cases divided by specialty and PowerPoint presentations with summaries from each chapter; extensive coverage of E/M documentation and chart audits; guidelines for auditing radiology and operating room records; and, information on how to ensure medical records which are compliant with current regulations.