General Principles of Medical Record Documentation

 

The principles of documentation listed below are applicable to all types of medical and surgical services in all settings.

 

1.   The medical record shall be complete and legible.

2.   The documentation of each patient encounter shall include:

·         reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results;

·         assessment, clinical impression, or diagnosis;

·         plan for care; and

·         date and legible identity of the patient and the author.

3. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.

4. Past and present diagnoses along with allowed conditions should be accessible to the treating and/or consulting physician.

5. Appropriate health risk factors should be identified.

6. The patient's progress, response to and changes in treatment, and revision of diagnosis should be documented.

7. The CPT, Level II and Level III HCPCS and ICD-9-CM codes reported on the CMS-1500 or C-19 must be supported by the documentation in the medical record.

 

Please note- For Evaluation and Management (E/M) services, the nature and amount of physician work and documentation varies by type of service, place of service and the patient's status. The general principles listed above may be modified to account for these variable circumstances in providing E/M services.