General Principles of Medical Record Documentation
As outlined by CMS, the principles of documentation apply to all types of medical and surgical services, in all settings. For E/M services, the nature and amount of physician work and documentation varies by type of service, patient’s status, and the place of service. The standards listed as follows may be modified to account for these varying circumstances in providing E/M services:
• The medical record shall be complete and legible.
• The documentation of each patient encounter shall include:
Reason for encounter and relevant history, physical examination findings, and prior diagnostic ...
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