Medical record documentation is required to record pertinent facts, findings, and observations about an individual’s health history including the past and present illnesses, examinations, tests, treatments, and outcome. The medical record chronologically documents the care of the patient and is an important element contributing to high quality care. The medical record should be complete and legible. Proper documentation facilitates:

• The ability of the physician and other health care professionals to evaluate and plan the patient’s immediate treatment, and to monitor his/her health care over time.
• Communication and continuity of care among the physicians and other health care professionals involved in the patient care.
• Accurate and timely claims review and payment.
• Appropriate utilization review and quality of care evaluations.
• Collection of data that may be used for research and education.

Basic Principles of Documentation:

Documentation of each patient encounter should include or provide reference to:

• Chief complaint and/or reason for the encounter.
• Relevant history, examination findings and prior diagnostic test results.
• Assessment, clinical impression or diagnosis and plan of care.
• Date and legible identity of health care professional.
• The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement must be supported by the documentation in the medical record.
• The confidentiality of the medical record should be fully maintained consistent with the requirements of medical ethics and of law.