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now more than ever your medical record documentation is being audited by various third-party payers and their contractors have you ever wanted to learn how to audit the records internally or make sure your records will stand up during an audit this class will help you do just that learn what you should look for not only in meeting the EM documentation guidelines but medical necessity as well our chartering workshop today is going to begin with the documentation guidelines the documentation guidelines first came about it was all based upon whats called a problem oriented medical record and this is how they teach our providers in residency during their training to document in their records and a problem oriented medical record they teach them the soap format which documents out what each area of the record should look like when youre looking at the soap format it does follow our documentation guidelines where the key components being history exam and medical decision making as you se
