> ## Documentation Index
> Fetch the complete documentation index at: https://docs.officeridge.com/llms.txt
> Use this file to discover all available pages before exploring further.

# Clinical logs

> Admission log, physician orders, audit checklists, and Medicare compliance tracking.

These tabs track the clinical documentation that determines whether your admissions are compliant.

## Admission Log

Patient admission records with attending physician and compliance status.

**Columns:** Patient · Admitted · Physician · Compliance

**Compliance** shows whether the admission has the documentation it needs. An admission without a
physician recorded is the most common gap.

## Physician Orders

Physician order records with compliance verification status.

**Columns:** Patient · Physician · Order Date · Compliance

<Warning>
  Services delivered without a valid physician order are not billable, and the care has already
  happened by the time you notice. Check order compliance at admission, not at billing.
</Warning>

**Order Date** matters as much as the order existing. An order dated after services began does not
retroactively authorize them.

## Audit Checklists

Audit checklist progress tracking for compliance reviews.

**Columns:** Date · Progress

Use these to work through a review systematically rather than sampling ad hoc.

## Medicare Tracking

Medicare compliance metrics with admission counts and compliance rates.

**Columns:** Period · Admissions · Compliant · Rate

| Field          | What it shows                           |
| -------------- | --------------------------------------- |
| **Admissions** | Total admissions in the period          |
| **Compliant**  | How many had complete documentation     |
| **Rate**       | Compliant as a proportion of admissions |

<Tip>
  **Rate** is a trailing indicator. By the time it drops, the affected admissions have already
  happened. Work the admission log and physician orders daily so the rate stays high by default.
</Tip>

## Checking a new admission

<Steps>
  <Step title="Confirm the attending physician is recorded">
    On the admission log entry.
  </Step>

  <Step title="Confirm a physician order exists">
    With an **Order Date** on or before the service start date.
  </Step>

  <Step title="Check compliance status on both">
    Both the admission and the order must show compliant.
  </Step>

  <Step title="Resolve gaps before services begin">
    A gap found now is a phone call. Found at billing, it is unbillable care.
  </Step>
</Steps>

## Reviewing the period

<Steps>
  <Step title="Check the Medicare compliance rate">
    Compare against previous periods.
  </Step>

  <Step title="Identify non-compliant admissions">
    The difference between **Admissions** and **Compliant**.
  </Step>

  <Step title="Find the missing documentation">
    Usually a physician order, or an order dated too late.
  </Step>

  <Step title="Work the audit checklist">
    Track your review progress so it can be evidenced.
  </Step>
</Steps>

## Troubleshooting

| Problem                                       | What to check                                                                        |
| --------------------------------------------- | ------------------------------------------------------------------------------------ |
| An admission shows non-compliant              | Usually a missing physician or physician order.                                      |
| An order exists but still shows non-compliant | Check **Order Date**. An order dated after services began does not cover them.       |
| The Medicare rate dropped                     | Compare **Admissions** against **Compliant** for the period and find the gaps.       |
| Claims deny for missing orders                | The order was not in place at the service date. Fix the process, not just the claim. |

## Related

<CardGroup cols={2}>
  <Card title="Care network" icon="stethoscope" href="/members/care-network">
    Physician records and NPIs.
  </Card>

  <Card title="Members" icon="users" href="/members">
    Member records and admission status.
  </Card>
</CardGroup>