What is documentation, and why is it important?
Medical record documentation is required to record pertinent facts, findings
and observations about an individual's health history including past and present
illnesses, examinations, tests, treatments and outcomes. The medical record
chronologically documents the care of the patient and is an important element
contributing to high quality care. The medical record facilitates:
This would include identifying demographic information for the injured worker
to image medical record documentation.
An appropriately documented medical record can reduce many of the issues associated with
bill processing and may serve as a legal document to verify the care provided, if necessary.
- The ability of the physician and other health-care professionals
to evaluate and plan the patient's immediate treatment and to monitor
his/her health care over time;
- Communication and continuity of care among physicians and other
health-care professionals involved in the patient's care;
- Accurate and timely bill review and payment;
- Appropriate utilization review and quality of care evaluations;
- Collection of data that may be useful for research and education.
What does BWC want and why?
Because we have an obligation to employers, they may request documentation that
shows services are consistent with the coverage provided. For this reason BWC requires
information to validate:
- The site of service;
- The medical necessity and appropriateness of the diagnostic and/or
therapeutic services provided;
- Services provided have been accurately reported;
- Services are related to the allowed claim condition.
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.
- The medical record shall be complete and legible.
- The documentation of each patient encounter shall include:
If not documented, the rationale for ordering diagnostic and other
ancillary services should be easily inferred.
Past and present diagnoses along with allowed conditions should be
accessible to the treating and/or consulting physician.
Appropriate health risk factors should be identified.
The patient's progress, response to and changes in treatment and revision
of diagnosis should be documented.
The CPT, Level II and Level III HCPCS and ICD codes reported on the
CMS-1500 or C-19 must be supported by the documentation in the medical record.
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.
- Reason for the encounter and relevant history, physical
examination findings and prior diagnostic test results;
- Assessment, clinical impression or diagnosis;
- Plan for care;
- Date and legible identity of the patient and the author.
To download and/or print the entire policy, click on the link below.