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. 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 below may be modified to account for these variable circumstances in providing E/M services.

1. The medical record should be complete and legible. 

2. The documentation of each patient encounter should include: 

• reason for 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 observer. 

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

4. Past and present diagnoses 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 and ICD-9-CM codes reported on the health insurance claim form should be supported by the documentation in the medical record.