General Principles of Medical Record Documentation

• The medical record should be complete and legible.
• The documentation of each patient encounter should include:
  • The reason for the encounter and relevant history, physical examination findings and prior diagnostic test results.
  • Assessment, clinical impression or diagnosis.
  • A plan of care.
  • The date and legible signature with credentials of the performing provider.
• The supervising provider, if applicable, should cosign the note.
• If abbreviations are used that are not standard medical abbreviations, a key should be included.
• The reason for the service should be clear and consistent with the diagnoses submitted.
• ICD-10-CM for services performed on or after 10/1/2015.
• If the service is a time based service, such as critical care (CPT 99291–99292), the time must be included in the documentation.

Posted 9/30/2024