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Printed Date: 9/22/2015
“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 the patient’s health history. Medical record documentation assists physicians and other health care professionals in evaluating and planning the 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 the patient’s insurance coverage and to validate:
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.
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Last Updated: 02/13/2018