Assessment & Review
Our clinical record assessment & review process entails providing educational presentations to develop a clear clinical picture for all clients prior to and upon admission. The assessment training will help improve the quality of care for all clients and increase the profitability.
Chart & Record Auditing
Our clinical chart and records auditing services include identifying deficiencies within the medical records for each individual department. We will provide key areas to audit thus providing opportunities to educate the department staff about proper documentation.
Instructor Led Training
We offer clinical documentation training (onsite or remotely). Training can be delivered on several different platforms depending on the individual need of the facility. During the training sessions we will identify the areas that require improvement and provide explanations as to why the change must be made. All departments will learn what documentation is required to obtain authorizations.
Our Process
- We will come in for an initial consultation
- We will review charts and complete our clinical documentation forms
- We will provide you with the results of our findings
- We will then discuss your options on how to correct our findings
Once a request for a consultation is received, we will send you an intake questionnaire to determine your needs. We will then contact you to schedule an initial consultation either in person or remotely. We can then proceed to audit your clinical charts using our proprietary clinical documentation format. Once we’ve identified and assessed your needs, we will develop a detailed project plan and explain exactly what we can do to improve your documentation and outline a customized training strategy.