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Documentation guidelines: evolution, future direction, and compliance

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History

The Current Procedural Terminology (CPT) 4 of the American Medical Association (AMA) incorporated new evaluation and management codes in 1992. The descriptors of the highest level office services (established patient, new patient, or physician referred office consultation) included language that described the physical examination as a comprehensive multisystem or single-system examination. However, there was no definition or clarification of what actually constituted a comprehensive multisystem

The importance of documentation

The medical record is a repository of historical information about the reasons for visits to physicians, the clinical course of symptoms and disease, the findings of tests and examinations and the outcomes of interventions. The medical record chronologically documents the care of the patient. It serves also to facilitate communication between physicians who provide consultative services or who collaborate in patient care. The record also provides important information used for research and

General principles of medical record documentation

The principles of documentation described below are applicable to all types of medical and surgical services. For evaluation and management services, the nature and amount of physician work and documentation varies by type of service, place of service, and the patient’s status.

  • 1.

    The medical record should be complete and legible.

  • 2.

    The documentation of each patient encounter should include • the chief complaint or reason for the encounter, and the relevant history, examination, and prior diagnostic

Ideal documentation guidelines

Documentation guidelines should follow the process of medical care and documentation rather than function as the structure that defines how a physician approaches a patient. The documentation guidelines should also emphasize the importance of the medical record in gathering accurate historical and examination information, development of working or final diagnoses, and development of diagnostic and therapeutic plans. Physicians do not approach patients with the idea that they must complete a

Conclusion

Documentation guidelines for evaluation and management services are still problematic, despite multiple efforts to develop a workable construct. This outcome reflects a more significant underlying structural problem with the codes for evaluation and management services. This is an opportune time for specialty societies to work with HCFA to undertake pilot studies that can provide helpful information for development of better guidelines and for modification of code descriptors and instructions

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Dr. Wood is Vice Chair of the Department of Medicine at Mayo Medical School

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