1995 DOCUMENTATION GUIDELINES

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: 

the ability of the physician and other healthcare professionals to evaluate and plan the patient’s immediate treatment, and to monitor his/her healthcare over time; 

communication and continuity of care among physicians and other healthcare professionals involved in the patient's care; 

accurate and timely claims review and payment; 

appropriate utilization review and quality of care evaluations; 

and collection of data that may be useful for research and education.

 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. 

WHAT DO PAYERS WANT AND WHY?

Because payers have a contractual obligation to enrollees, they may require reasonable documentation that services are consistent with the insurance coverage provided. They may request information to validate:

• the site of service; 
• the medical necessity and appropriateness of the diagnostic and/or therapeutic services provided; 
• and/or that services provided have been accurately reported 

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 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 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 or billing statement should be supported by the documentation in the medical record.