A Brief History

Documentation Reminder

The general principles of medical record documentation for E/M services are as follows:

• Record should be complete and legible;
• Documentation of each patient encounter should include, at a minimum:
  • The reason for the visit, relevant history, physical exam findings, and prior diagnostic test results;
  • Assessment, clinical impression, or diagnosis;
  • Plan for care; and
  • Date and legible identity of the observer;
• Rationale for ordering diagnostic and other ancillary services should be documented or easily inferred;
• Past and present diagnoses should be available to the treating and/or consulting physician;
• Appropriate health risk factors should be identified;
• Document patient progress, response to and changes in treatment, and revision of diagnosis; and
• Documentation should support the CPT and ICD-9-CM codes reported for billing.

Some of these principles can be adjusted as reasonably necessary to account for the varying circumstances encountered by physicians when providing E/M services.—CP