Revised: July 3, 2006
The Importance of Documentation
Medical record documentation is required to record significant 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:
- The ability of the physician and other health care professionals to evaluate and plan the patient’s immediate treatment and to monitor their health care over time.
- Communication and continuity of care between physicians and other health care professionals involved in the patient’s care.
- Accurate and timely claims review and payment.
- Appropriate utilization review and quality of care evaluations.
An appropriately documented medical record can reduce many of the “hassles” associated with claims processing and may serve as a legal document to verify the care provided, if necessary.
Tips for Documenting
- The medical record should be complete and legible.
- Each patient encounter should include:
- the date
- the reason for the encounter
- appropriate history and physical exam
- review of lab, x-ray data and other ancillary services
- assessment and a plan of care, including discharge plan (if appropriate)
- Past and present diagnoses should be accessible to the treating and/or consulting physician
- Reasons for and results of x-rays, lab tests and other ancillary services should be documented or included in the medical record
- Relevant health risk factors should be identified.
- Patient’s progress, including response to treatment, change in treatment, change in diagnosis, and patient non-compliance should be documented.
- The written plan of care should include, when appropriate:
- Treatments and medications, specifying frequency and dosage
- Any referrals and consultations
- Patient/family education
- Specific instructions for follow up
- The documentation should support the intensity of the patient evaluation and/or treatment, including thought processes and the complexity of medical decision-making
- All entries to the medical record should be dated and authenticated by the physician/provider signature.
- The CPT/ICD-9-CM codes reported on the CMS-1500 form should reflect the documentation in the medical record.
Remember:
- Provide only the services the patient needs (services that address the chief complaint or reason for the visit or clearly document the need if not related to the presenting problem)
- Clearly and legibly document the services rendered in the medical record
- Bill the CPT/ICD-9-CM codes that most accurately reflect the services rendered and documented
- Acceptable documentation is based on medical necessity, not volume of documentation
