General Surgery Coding Alert

“Get Your Medical Records in Top Shape With These 3 Tips” on page 5 exhorted you to keep your medical records consistent, current, and complete.

To do that, you need to know the core elements that should be in your documentation. The National Committee for Quality Assurance (NCQA) is the organization responsible for the Healthcare Effectiveness Data and Information Set (HEDIS) performance improvement tool, and they emphasize the following six core elements of medical record documentation:

• Significant illnesses and medical conditions are indicated on the problem list.
• Medication allergies and adverse reactions are prominently noted in the record. If the patient has no known allergies or history of adverse reactions, this is appropriately noted in the record.
• Past medical history (for patients seen three or more times) is easily identified and includes serious accidents, operations, and illnesses. For children and adolescents (18 years and younger), past medical history relates to prenatal care, birth, operations, and childhood illnesses.
• Working diagnoses are consistent with findings.
• Treatment plans are consistent with diagnoses.
• There is no evidence that the patient is placed at inappropriate risk by a diagnostic or therapeutic procedure.

Resource: See the NCQA Guidelines for Medical Record Documentation.