Are there any special components that should be included in medical record documentation?

Frequently Asked Questions

Are there any special components that should be included in medical record documentation? Yes. Medical records (including records related to a clinical research study) should be complete, legible, and include the following information: Reason for encounter, relevant history, findings, test results and date of service Assessment and impression of diagnosis Plan of care with date and legible identity of the observer Documentation that supports that the rendering/billing provider indicated on the claim is the healthcare professional providing the service Records should not only substantiate the service performed, but also the required level of care

Yes. Medical records (including records related to a clinical research study) should be complete, legible, and include the following information:

Reason for encounter, relevant history, findings, test results and date of service
Assessment and impression of diagnosis
Plan of care with date and legible identity of the observer
Documentation that supports that the rendering/billing provider indicated on the claim is the healthcare professional providing the service
Records should not only substantiate the service performed, but also the required level of care