During high school, college and medical school I took many exams. The tests were of two general formats, quantitative or qualitative. One was multiple choice; answers were circles on the page of questions or marked on a separate answer sheet by darkening empty circles. The second format was a page of questions which I answered by writing in a blue book of blank pages.
Patient medical records have two similar formats. The quantitative category consists of data from diagnostic testing such as radiographic images or blood counts. The results and the quality controls, not just the printed report in the patient’s chart, are available for review by any third party (payer). This is analogous to my multiple choice format in college testing.
The second category, the qualitative component, is the written record created by a provider from examining and talking to the patient one-on-one. When I practiced medicine, I recorded office visits on a blank page analogous to my college blue book. When I added a midlevel practitioner, I created a template on our “blank page,” and the two of us recorded information on one order. No third party (payer) could review more than my written note, and reviewing the primary data would have required video documentation of the patient encounter or an independent account from the patient.
The claim for financial reimbursement for medical care is transmitted to the patient’s health insurer in universal numeric codes describing the service, the date and place of the service, as well as the complexity of the encounter. Written documentation must be obtained that the provider and patient have agreed that the provider may receive the payment directly. The third purchases this claim.
Audits by third party payers of health care in the United States assess the accuracy of the translation of the office visit note into the numeric claim form, not the contents of the note itself.