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Documentation is more than just notes that record the basics of a patient encounter. It is a blueprint to track each individual patient’s care. Providers need to adhere to a general set of principles to reduce risk and ensure consistency within the documentation process.

According to the Centers of Medicare and Medicaid Services (CMS), there are ten principles to adhere to in the documentation of a medical record. Let’s take a look:

Ten Principles of Documentation for Medical Records

1

The medical record should be complete and legible

2

The documentation of each patient encounter must include the following:

  • Date of service
  • Reason for the patient encounter
  • History and physical exam (as appropriate per the chief complaint)
  • Review of any diagnostic testing or imaging / ancillary services
  • Assessment
  • Treatment plan

3

Past and present diagnoses should be accessible to the treating/consulting physician

4

The rationale and results of any ancillary services should be documented in the record

5

Identification of any relevant health risk factors must be included

6

Include documentation of the patient’s progress, treatment response, changes in treatment plan or diagnosis, as well as patient non-compliance

7

A documented Treatment Plan should include:

  • Treatments applied/utilized
  • Current medications (including dosage and frequency)
  • Referrals/consultations
  • Patient/family education
  • Specific follow-up care instructions

8

Documentation should include reasoning and support for any diagnostic or ancillary services with clearly stated or inferred rationale

9

All entries to the medical record must be dated and authenticated with a handwritten or electronic signature Stamped signatures are not appropriate or acceptable

10

The CPT/ICD-10 codes reported on the payer claim form should reflect the documentation within the patient’s medical record

Ensuring that documentation meets current compliance standards is often a task that many providers consider only moderately important – until they are audited – and then it is too late. However, when it comes to making positive change, there is no better time to start than the present! By adhering to these principles and having a standard process, your documentation will more accurately reflect your care and the patient progress.

Dr. Colleen Auchenbach graduated with a Doctor of Chiropractic from Cleveland University Kansas City in December of 1998 and practiced for over 20 years. Her interest in Medical Compliance began when she earned the 100-hour Insurance Consultant/Peer Review certification from Logan University in 2015. She has been a certified Medical Compliance Specialist-Physician since 2016. In November 2020, Dr. Auchenbach joined the excellent team at KMC University as a Specialist and, as part of this dedicated team, is determined to bring you accurate, current, reliable information. You may reach her by email at info@kmcuniversity.com or by calling (855) 832-6562.

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By Team KMCU

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