10 Principles of Documentation for Medical

Records

From the Centers for Medicare and Medicaid Services and TrailBlazer Health Enterprises,
LLC
1. The medical record should be complete and legible.
2. The documentation of each patient encounter should include:
the date;
the reason for the encounter;
appropriate history and physical exam in relationship to the patients chief complaint;
review of lab, x-ray data and other ancillary services, where appropriate;
assessment; and
a plan for care (including discharge plan, if appropriate)
3. Past and present diagnoses should be accessible to the treating and/or consulting physician.
4. The reasons for and results of x-rays, lab tests and other ancillary services should be
documented or included in the medical record.
5. Relevant health risk factors should be identified
6. The patients progress, including response to treatment, change in treatment, change in
diagnosis, and patient non-compliance, should be documented.
7. The written plan for care should include, when appropriate:
treatments and medications, specifying frequency and dosage;
any referrals and consultations;
patient/family education; and
specific instructions for follow-up.
8. The documentation should support the intensity of the patient evaluation and/or the treatment,
including through processes and the complexity of medical decision-making s it relates to the
patients chief complaint for the encounter.
9. All entries to the medical record should be dated and authenticated.

10. The CPT/ICD-9-CM codes reported on the CMS-1500 claim form should reflect the
documentation in the medical record.


Medical record
From Wikipedia, the free encyclopedia
This article is about the documentation of a patient's medical history. For digital records, see
electronic medical record and electronic health record. For the New York journal published by
the Washington Institute of Medicine, see Medical Record (journal). For the BBC Radio 4
medical programme, see Case Notes (radio show).
The terms medical record, health record, and medical chart are used somewhat
interchangeably to describe the systematic documentation of a single patient's medical history
and care across time within one particular health care provider's jurisdiction.
[1]
The medical
record includes a variety of types of "notes" entered over time by health care professionals,
recording observations and administration of drugs and therapies, orders for the administration of
drugs and therapies, test results, x-rays, reports, etc. The maintenance of complete and accurate
medical records is a requirement of health care providers and is generally enforced as a licensing
or certification prerequisite.
The terms are used for both the physical folder that exists for each individual patient and for the
body of information found therein.
Medical records have traditionally been compiled and maintained by health care providers, but
advances in online data storage have led to the development of personal health records (PHR)
that are maintained by patients themselves, often on third-party websites.
[2]
This concept is
supported by US national health administration entities
[3]
and by AHIMA, the American Health
Information Management Association.
[4]


importance

A medical record folder being pulled from the records
Because many consider the information in medical records to be sensitive personal information
covered by expectations of privacy, many ethical and legal issues are implicated in their
maintenance, such as third-party access and appropriate storage and disposal.
[5]
Although the
storage equipment for medical records generally is the property of the health care provider, the
actual record is considered in most jurisdictions to be the property of the patient, who may obtain
copies upon request.

Importance of Documentation
Medical record documentation is required to record pertinent facts, findings, and observations
about an individuals 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
patients 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.
purpose

Primary Purpose of a Medical Record
Are we losing sight of the primary purpose of a patient medical record, which is to support
patient care?

Narrative notes serve several purposes by helping physicians and other caregivers:
1. Decide upon the appropriate course of care and provide rationale
2. Create context for a patients story, and make one patient memorable from the next
3. Provide continuity of care over time and among clinicians
4. Communicate with referring and consulting colleagues
The most important part of the medical record is the physicians narrative note, which documents
the thought process for why a course of treatment is decided upon after each patient encounter.
Narrative notes also provide a useful summary of the other information contained in a medical
record, such as the results of labs, imaging and other diagnostic tests.

Over time, the medical record has been commandeered for other purposes, most notably as a
legal record of care provided and as the basis for insurance billing and payment.
Although clinical documentation plays a central role in EHRs and occupies a substantial
proportion of physicians time, documentation practices have largely been dictated by billing
and legal requirements. Yet the primary role of documentation should be to clearly describe
and communicate what is going on with the patient.
Gordon Schiff, MD & David Bates, MD -- NEJ M 25 Mar 2010