Medical Documentation Standards

The way medical practitioners document the services they provide impacts a patient's medical record, as well as how insurance carriers interpret claims and how much the doctors get paid. As such, medical documentation standards help to make sure patients' services are captured accurately through detailed notes.

Function

• When medical services are provided to patients, doctors are required to document what happened during the appointment, what services were provided (known as coding) and list any medications that were prescribed. This information is valuable in maintaining a complete patient chart for quality and billing purposes. It is also beneficial for auditing purposes, so that there is a distinct documentation trail of a patient's medical history.

Features

• Documentation notes must contain the name of the patient, the date of the appointment, the medical codes for the services, the patient's diagnosis and the duration of the appointment. Medicare and Medicaid healthcare providers must be sure to adhere to state and federal documentation standards to protect themselves against allegations of waste, fraud and abuse, according to the New York State Department of Health.

Considerations

• Medical documentation should be fact-based, but also provide the doctor's personal assessment based on what he or she observes from the patient. Evidence of progress, for example, should be documented. When measurable data is present in patient charts, doctors have a way of comparing progress, or regress, so that they can evaluate health patterns and help with prognoses and diagnoses.