Documentation review is an integral part of the medical visit process. It involves accurately recording every aspect of a patient’s visit, including complaints, medical recommendations, necessary tests, and treatments. Since this documentation serves as the foundation for medical coding and billing, it is essential that it is clear, complete, and accurate. In healthcare revenue cycle management (RCM), the documentation review process involves examining medical records, patient charts, and other related documents to ensure they are correct, comprehensive, and compliant with regulatory standards. The reviewer will also ensure that the documentation is legible and that all required signatures are included.

The process of documenting a medical visit is vital, as it includes noting all events and interactions, such as patient complaints, proposed treatments, and any required testing. Properly documented clinical records enhance RCM, enabling healthcare providers to deliver the right care while ensuring they are reimbursed for their services. Accurate documentation supports proper coding, faster payments, and quicker reimbursements.

The Processing and Data Overview is an in-depth analysis of claim formatting and medical record documentation, which helps identify potential gaps and risks that require attention. This analysis reduces the risk of audits and streamlines the processing and reporting workflow.