Documentation’s Top Priority

By: Diana Williams BS CPC CCS-P CCS CPMA

The primary purpose of health record documentation is for continuity of patient care, and as a means of communicating among all healthcare providers. This clinical documentation captures the patient’s medical condition(s); hence, attention to documentation should be a priority for clinical providers.

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 care of the patient, and is an important element contributing to high quality care. It also facilitates:

  • The ability of providers to evaluate and plan the patient’s immediate treatment and to monitor his/her health care, 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
  • Collection of data that may be useful for research and education

The Ideal Record

CMS provides guidelines to assure that every patient’s health record contains quality documentation. Occasionally review the guidelines to keep them “fresh” in your mind. CMS general principles of medical record documentation for reporting of 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:
    • Reason for encounter and relevant history
    • Physical examination findings and prior diagnostic test results
    • Assessment, clinical impression, and diagnosis
    • Plan for care
    • 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 for 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 form should be supported by documentation in the medical record.

In defining “complete and legible,” CMS gives further guidance:

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  • In addition, consistent with sound clinical practice, all medical records, including progress notes and treatment plan, should be legible and complete, have the date of service, and should be promptly signed and dated by the person (identified by name and discipline) who is responsible for ordering, providing or evaluating the service furnished.
  • CMS intends for physicians and other providers who document treatment for Medicare beneficiaries (and who submit claims for FFS reimbursement) to recognize the importance of legible documentation to avoid claim denials.
  • Many claim denials occur 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.
John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 406 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

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