Saturday, June 25, 2011

Medical record documentation tips

Tips for Medical Record Documentation

•    The medical record should be complete and legible, utilizing widely accepted and recognized abbreviations and symbols. It should also be dated and authenticated by the physician.

•    Documentation should support the intensity of the evaluation and/or treatment, including thought processes and the complexity of medical decision-making.

•    The codes recorded on the Medicare claim should be supported by the documentation in the medical record.

•    The patient’s progress including response to treatment, change in diagnosis and patient non-compliance should be documented.

•    Documentation of each encounter should include:
o    The patient’s name and date of service (including the backside of double-sided forms).
o    The reason for the encounter.
o    An appropriate history and physical exam including any relevant health risk factors.
o    The reason, results and review of diagnostic tests and ancillary services.
o    Patient assessment and a treatment plan, including a discharge plan (when appropriate). The written treatment plan should include: treatments and medications specifying frequency and dosage; labs and tests; referrals and consultations; patient/family education; and specific follow-up instructions.
o    The clear identity and professional credentials of all people who contributed to the service and/or record, and who contributed which portion(s) of the service and/or record.

An appropriately documented medical record can expedite claims processing, reduce errors and may serve as a legal document to verify the care provided, if necessary. In addition to the above general documentation tips, the following are links to minimum documentation recommendations based on specific services.

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