Let’s review some general principles of medical record documentation. 

The principles of documentation listed below are applicable to all types of medical

and surgical services in all settings. For Evaluation and Management (E/M)

services, the nature and amount of physician work and documentation varies by

type of service, place of service and the patient's status. The general principles listed

below may be modified to account for these variable circumstances in providing

E/M services.

1. The medical record should be complete and legible.

2. The documentation of each patient encounter should include:

• reason for the encounter and relevant history, physical examination

findings and prior diagnostic test results;

• assessment, clinical impression or diagnosis;

• plan for care; and

• date and legible identity of the observer.

3. If not documented, the rationale for ordering diagnostic and other ancillary

services should be easily inferred.

4. Past and present diagnoses should be accessible to the treating and/or

consulting physician.

5. Appropriate health risk factors should be identified.

6. The patient's progress, response to and changes in treatment, and revision of

diagnosis should be documented.

7. The CPT and ICD-9-CM codes reported on the health insurance claim form

or billing statement should be supported by the documentation in the

medical record.

Do you have any specific operations topics that you want us to tackle next?  Any questions for us?  Have a great day!