Documentation guidelines available

Proper medical record documentation is essential for continuity of care and serves to document the care provided.

Remember to make any handwritten notes legible when documenting in the patient’s medical record. Also, the CPT and ICD-9-CM codes billed by the provider of care should be supported by the documentation in the medical record. 

Each patient encounter should include:

• Reason for the visit that includes a relevant history and physical examination
• Assessment, clinical impression, or diagnosis that includes whether the condition is stable, improved, or worse
• Plan for care
• Date and signature of the provider of care

By following these basic guidelines, you are using good documentation practices for your patients while meeting the standards of third-party payers.

A full list of guidelines for medical records documentation can be found at upmchealthplan.com. Once on the site, go to “For Providers,” and log in. The guidelines are in the “Reference Library.”