Physicians Documentation

Patients place a significant level of trust in their physicians. Patients rely on their physicians to make sound medical decisions about them and document them accordingly. Payers and the government also trust physicians to document appropriately in the health record so quality care can be rendered and appropriate reimbursement issued by the payer. The information a physician documents in the health record impacts the patient first and foremost. All physicians caring for the patient and payers connected to the physicians need to coordinate their care and documentation. See chapter 16, Fraud and Abuse Compliance, for information on regulatory laws that directly and indirectly govern physician documentation. Those laws fall into the general category of fraud and abuse laws, but the False Claims Act and Anti-Kickback Statute have significant documentation compliance ­jurisdiction for physicians.