This is in the CMS E&M guidelines, page 4:
GENERAL PRINCIPLES OF EVALUATION AND MANAGEMENT DOCUMENTATION
â€śIf it isnâ€™t documented, it hasnâ€™t been doneâ€ť is an adage that is frequently heard in the
health care setting.
Clear and concise medical record documentation is critical to providing patients with
quality care and is required in order for providers to receive accurate and timely
payment for furnished services. Medical records chronologically report the care a
patient received and are used to record pertinent facts, findings, and observations about
the patientâ€™s health history. Medical record documentation assists physicians and other
health care professionals in evaluating and planning the patientâ€™s immediate treatment
and monitoring the patientâ€™s health care over time.
Hope this helps.
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