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