Getting to the Documentation Basics: History

Nurse practitioners, like other types of health care providers, often find it difficult to keep up with all the recordkeeping required by each patient encounter. Over time, clinicians often fall into using shortcuts, abbreviations, or habits of stressing the things that are important in a patient population or practice. Sometimes those changes are acceptable, but when it comes to documentation for Medicare reimbursement, the records have to meet precise standards. To deviate from them often means a denial for reimbursement.