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6:37:54 PM CDT
Friday, May 22, 2015

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Documentation Guidelines
Medical documentation should be in SOAP format and provide detailed information, including the following:
  • Reason for visit
  • Body part or area where treatment is provided (e.g. thoratic)
  • Capabilities
  • Progress/improvement
  • Time (if applicable)

WSI developed the E/M Documentation Guidelines as a provider reference that outlines specific documentation components reviewed in WSI's auditing process.

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