To ensure that medical record documentation is accurate, the following principles should be followed:
•
The medical record should be complete and legible.
•
The documentation of each patient encounter should include:
o Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results.
o Assessment, clinical impression, or diagnosis.
o Medical plan of care.
o
Date and legible identity of the observer.
•
If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.
•
Past and present diagnoses 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 Current Procedural Terminology (CPT) and International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.
Page 2 of the Evaluation and Management Services Guide
http://www.cms.hhs.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf