Book excerpt: General E/M documentation principles

By Karen Newhouser, RN, BSN, CCDS, CCS, CCM, CDIP

A common theme that plays a critical role in portraying the patient encounter accurately in both the inpatient and outpatient environments is complete and precise documentation. General principles of medical record documentation apply to all types of medical and surgical services in all settings.

Although physicians’ evaluation and management (E/M) services vary in several ways, such as the nature and amount of physician work required, these general principles help ensure that medical record documentation for all E/M services is appropriate.

For example, the medical record must be complete and legible. Although legibility represents less of a problem with computerized systems and electronic health records, many physician practices and, indeed, healthcare systems continue to operate with hybrid (part paper, part electronic) systems—and physicians’ handwriting skill remains infamous.

Additionally, the documentation of each patient encounter should include the following:

• The reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results
• Assessment, clinical impression, or diagnosis
• Medical plan of care
• Date and legible identity of the observer

If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred. Past and present diagnoses should be accessible to the treating and/or consulting physician, and appropriate health risk factors should be identified. Furthermore, the physician needs to document the patient’s progress, response to/and changes in treatment, and revision of diagnosis. The diagnosis and treatment codes reported on the health insurance claim form or billing statement should be supported by documentation in the medical record.

To maintain an accurate medical record, the physician needs to document the services provided during the encounter, or as soon as reasonable after the encounter. Memory fades after an event, and if the provider is documenting at the end of the day, there is a real chance of leaving out documented element(s) that could support a higher level of code assignment.

Editor’s note: This article is an excerpt from the CDI Specialist’s Guide to Evaluation and Management.