Clinical Documentation and Compliance

Documentation apart of the medical record has many aspects involved.  Whether one has an intrinsic interest in medical records or not, everyone wants to get paid and, for most physicians, that still involves a bill, usually to an insurance carrier. Unfortunately, there are documentation requirements to get paid. Merely submitting a billing code is not sufficient.

The University of North Texas has summarized the minimum required documentation pretty well here in their Clinical Documentation and Compliance Manual, however we will outline a few of the important aspects of them below.

Every Patient Encounter should include:

  • reason for the encounter and relevant history;
  • physical examination findings and prior diagnostic test results;
  • assessment, clinical impression, or diagnosis;
  • plan for care; and
  • date and legible identity of the observer.
If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.
Appropriate health risk factors should be identified.

The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented.

The CPT and ICD9 codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

These are just a few of the very important things that must be included to maintain documentation and compliance.


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