Text Documentation

As a reminder of the importance of text documentation, we refer you to the CCR's Volume I IX.2.2 Accuracy - Quality Control:

"Accuracy is the extent to which the data submitted has been correctly coded and matches the information in the medical record and have been correctly coded. It encompasses accurate abstracting, correct application of coding rules, text documentation to support all codes, and correct entry into a retrieval from the computer."

In addition,  click here for the link to the CCR Text Documentation Guidelines.