Physician Query Process: Part 4: Dealing With Legibility Issues And Challenging Handwriting?

**This is part 4 of an 11 part series from Libman Education.  This is good information.  More Information on the query process can be found at AHIMA.org

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Physician Query Process: Part 4: Dealing With Legibility Issues And Challenging Handwriting?

by Christopher G. Richards, RHIA, CCS, Senior Associate, Barry Libman, Inc.

As part of a continuing series of discussions relevant to the coding community, Libman Education presents this 11-part series on the importance of a well implemented physician query process. 

We’ve all seen this:

Handwritten and illegible entries in the patient health record are an important consideration in the query process. It is important to decide when bad handwriting rises to the level of a physician query.

In general, if your inability to read certain documentation is clearly going to impact your ability to assign an accurate code, then you need to consider a query.

From a quality of care and risk management perspective, illegible entries can:

• Cause miscommunication among clinicians about the patient’s condition
• Result in improper care and cause serious patient injury
• Raise questions of legal viability
• Easily lead to poor data quality and incorrect reimbursement
• Cause data collection, billing and reporting errors

- See more at: http://www.libmaneducation.com/physician-query-process-part-4-dealing-with-legibility-issues-and-challenging-handwriting/#sthash.uUK5SUi1.dpuf