December 2018

December 2018

Principles of Documentation

Mitigate Your Risk

Your documentation is more than just mere notes to record the basics of a patient encounter. It is your blueprint to build upon each individual patient’s care. For this reason, it’s important for a provider to have a general set of principles to adhere to as a guideline to reduce risk and ensure congruency within the documentation process.

According to the Center of Medicare and Medicaid Services (CMS), there are ten principles to adhere to in the documentation of a medical record. Let’s take a look:


  1. The medical record should be complete and legible

  2. The documentation of each patient encounter should include the following:

    • Date of service

    • Reason for the patient encounter

    • History and physical exam (as are appropriate per the chief complaint)

    • Review of any diagnostic testing or imaging / ancillary services

    • Assessment

    • Treatment plan

  3. Past and present diagnoses should be accessible to the treating/consulting physician

  4. The rationale and results of any ancillary services should be documented in the record

  5. Identification of any relevant health risk factors should be included

  6. Include documentation of the patient’s progress, treatment response, changes in treatment plan or diagnosis, as well as patient non-compliance

  7. A documented Treatment Plan should include:

    • Treatments applied/utilized

    • Current medications (including dosage and frequency)

    • Referrals/consultations

    • Patient/family education

    • Specific follow-up care instructions

  8. Documentation should include reasoning and support for any diagnostic or ancillary services with clearly stated or inferred rationale

  9. All entries to the medical record should be dated and authenticated with a hand written or electronic signature. Stamped signatures are not appropriate or acceptable

  10. The CPT/ICD-10 codes reported on the payer claim form should reflect the documentation within the patient’s medical record

Ensuring that documentation meets current compliance standards is often a task that many providers consider only moderately important, yet non-urgent - until they are audited - and then it is too late. However, when it comes to making positive change, there really is no better time to start than the present! For improved reimbursement and peace of mind, be sure to visit to help you streamline and simplify your documentation.