Over the years, I have read countless clinical notes from hundreds of orthotists and prosthetists. Using those notes, I have fought audits, assessed the contents for prior approvals and authorizations and for compliance with Centers for Medicare & Medicaid Services (CMS) regulations, and just plain tried to figure out what the notes were supposed to communicate. As you may imagine, clinical notes are anything but standardized in O&P. While some are quite good, others range from very short notes with a few sentences to several rambling pages that lack paragraphs, headings, or direction. With that in mind, I have suggestions to improve your O&P clinical notes.
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