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
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