decisionhealth Newsletters, Answer Books - 2009 Issue 6 (June)
Evaluation and Management Services / Documenting telephone care
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Article Overview
This short guidance article is for clinicians, coders, and documentation staff who need to understand the recordkeeping expectations for telephone care. It focuses on the general documentation elements that should be captured in the medical record and situates the topic within evaluation and management services.
Why This Topic Matters
Telephone encounters can affect how care is documented and audited. Clear documentation helps support the medical record and distinguishes telephone care from other E/M-related services.
What You Will Learn
- What information should be recorded for telephone encounters
- Which general documentation elements are relevant to telephone care
- How telephone documentation fits within broader evaluation and management services
- What kinds of encounter attributes may need to be captured in the medical record
Who Should Read This
- Physicians
- Nurses
- Medical coders
- Clinical documentation specialists
- Billing staff
- Practice managers
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