E/M Weekly Tip: General Principles

There are general principles of medical record documentation that are applicable to all types of medical and surgical services in all settings. While E/M services vary in several ways, such as the nature and amount of physician work required, the following general principles help ensure that medical record documentation for all E/M services is appropriate:
  • The medical record should be complete and legible
  • 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
    • Medical plan of care
    • 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 diagnosis and treatment codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record
Please see Evaluation and Management Services on the CMS website for more information.