Set Forth the Basics of Good Medical Record Documentation

Continuity of care, provider communication, and optimal reimbursement begin in a patient’s chart.

by Diana Williams, BS, CPC, CPMA, CCS-P, CCS
It’s always best to examine your daily routines periodically. When any task — such as documenting in the medical record — becomes routine, details are sometimes overlooked. Carefully consider what good documentation should contain to ensure this doesn’t happen.
Documentation’s Top Priority
According to the Centers for Medicare & Medicaid Services (CMS), “General Principles of Medical Record Documentation,” medical record documentation is required to record pertinent facts, findings, and observations about a patient’s health history, including past and present illnesses, examinations, tests, treatments, and outcomes. The medical record chronologically documents the patient’s care and is an important element contributing to high quality care. It also facilitates:

  • A provider’s ability to evaluate and plan the patient’s immediate treatment and to monitor his or her healthcare over time
  • Communication and continuity of care among providers involved in the patient’s care
  • Accurate and timely claims review and payment
  • Appropriate utilization review and quality of care evaluations
  • Data collection that may be useful for research and education

Ideal Recordkeeping
CMS provides guidelines to help ensure every patient’s health record contains quality documentation. General principles of medical record documentation for reporting medical and surgical services for Medicare payment include (when applicable to the specific setting/encounter):

  • Medical records should be complete and legible.
  • Documentation of each patient encounter should include:
  • The reason for the encounter and relevant history;
    • Physical examination findings and prior diagnostic test results;
    • Assessment, clinical impression, and diagnosis;
    • Plan of care; and
    • Date and legible identity of 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.
  • Patient’s progress, response to changes in treatment, and revision of diagnosis should be documented.
  • CPT® and ICD-9-CM codes reported on health insurance claim forms should be supported by documentation in the medical record.

CMS gives further guidance when defining “complete and legible:”

  • All medical records (including progress notes and a treatment plan) should be legible and complete, have the date of service, and should be signed and dated promptly by the person (identified by name and discipline) who is responsible for ordering, providing, or evaluating the furnished service.
  • Physicians and other providers who document treatment for Medicare beneficiaries (and who submit claims for fee-for-service reimbursement) should recognize the importance of legible documentation to avoid claims denials.
  • Many claims are denied because a provider/supplier did not submit sufficient documentation to support the service/supply billed (fails to demonstrate it is reasonable and medically necessary).
  • For every service billed, a provider must indicate the specific sign, symptom, or patient complaint necessitating the service.

Amending the Record
Occasionally, upon review, a provider may discover certain entries related to actions actually performed at the time of service were not properly documented or entered. CMS is aware that amendments, corrections, and delayed entries occur in the medical record, and stipulates that they must:

  1. Clearly and permanently identify an amendment, correction, or delayed entry, as such.
  2. Clearly indicate the date and author of an amendment, correction, or delayed entry.
  3. Not delete, but rather clearly identify all original content.

Timeliness of Documentation
A provider should not submit a claim to Medicare until the documentation is completed. Until the practitioner completes the documentation for a service, including the signature, the claim cannot be submitted to Medicare.
Practitioners are expected to complete the documentation of services during or as soon as practicable after it is provided to maintain an accurate medical record. CMS does not provide a specific time in which documentation must be completed, but a reasonable expectation is no more than a couple of days after the service is rendered.
Details Make the Difference
Paying attention to basic documentation guidelines plays a major role in promoting accurate coding, timely billing, and helping to ensure optimal reimbursement from payers.
Adopt best practices to your current processes, especially because ICD-10-CM/PCS will require more specificity in documentation. The delayed adoption of ICD-10-CM/PCS to October 2015 allows enough time to become familiar with necessary documentation details.
When documentation is incomplete, ask the provider for clarification so that you may code the record correctly. Due to clinical schedules, providers may not be available to talk about documentation with you during business hours, so create a regular time (end of the day, one day a week) to meet with providers to address coding/documentation questions. A team approach will help keep everyone on track today and prepare for the changes ahead.
Change Request (CR) 2520, Provider Education Article
Medicare Benefit Policy Manual, Pub. 100-02, Chapter 2, Section 30
“Medicare Claim Submission Guidelines” Fact Sheet, ICN 906764
MLN Matters® SE1237: Importance of Preparing/Maintaining Legible Medical Records
Social Security Act, Section 1862(a)(1)(A)
CMS Internet-only Manual (IOM), Pub. 100-04, Chapter 12, Section 30.6.1: Timeliness

Diana Williams, BS, CPC, CPMA, CCS-P, CCS, has over 30 years of experience in healthcare as a consultant, coder, educator, auditor, manager, and medical insurance professional. She is a multispecialty surgical coder, specializes in evaluation and management audits, and works in clinical documentation improvement. Williams is a member of the Pensacola, Florida, local chapter. You can reach her at

Renee Dustman
Follow me

About Has 729 Posts

Renee Dustman, BS, AAPC MACRA Proficient, is managing editor - content & editorial at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 30 years' experience in journalistic reporting, print production, graphic design, and content management. Follow her on Twitter @dustman_aapc.

One Response to “Set Forth the Basics of Good Medical Record Documentation”

  1. Samuel says:

    It’s a really very useful and also very informative blog for me. Thanks a lot for sharing the blog and also the useful information’s. Appreciate this article to help us read between the lines to get to the truth. Visit us at 75health