Evaluation and Management Services: Principles of Medical Record Documentation

“If it isn’t documented, it hasn’t been done” 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 a patient’s health history. Medical record documentation assists physicians and other health care professionals in evaluating and planning a patient’s immediate treatment and monitoring the patient’s health care over time.

Health care payers may require reasonable documentation to ensure that a service is consistent with a patient’s insurance coverage and to validate:

• The site of service
• The medical necessity and appropriateness of the diagnostic and/or therapeutic services provided and/or
• That services furnished have been accurately reported

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 of care
   • 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 diagnosis codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record