Understanding Medical Documentation Guidelines

Keeping accurate records is integral to your day-to-day job as a healthcare professional. These documents help you, your patients and other providers stay in the loop.

Read on to learn why these records are crucial to your job and the medical documentation guidelines you should follow.

Why Is Documentation Important in Healthcare?

The importance of accurate documentation in healthcare can’t be understated. Aside from patient care, it’s one of the most crucial things you do as a physician. But what makes proper medical documentation so vital?

There are many reasons physicians should know how to document patient records correctly, from laws to quality of care. Benefits of medical documentation include:

Continuity and Quality of Care

One of the most crucial parts of accurate records is continuity and quality of care. When you explain everything clearly, you can ensure patients receive appropriate care and reduce redundancies in evaluation and treatment across care teams.

Communication

You’re likely not the only doctor your patients have ever seen, meaning a medical record is critical for provider communication. Any practitioner they see should be able to easily access patient documents and understand their concerns and treatment plans.

Compliance

All healthcare providers operate under regulations from the state and federal governments. Between the Health Insurance Portability and Accountability Act (HIPAA) protecting patient privacy and your state’s licensing requirements, health records can help you avoid fines and grievances.

For other programs, like Medicare and Medicaid, accurate documentation helps ensure they pay the right amount of money to the correct people.

Risk Reduction

Healthcare involves risks, including payment audits, patient grievances and malpractice claims. Medical records make it easier for your team to provide evidence of care or treatment provided should someone file one of these claims.

Well-organized documentation can help you:

• Respond to customer service inquiries or complaints
• Avoid malpractice claims
• Reduce liability and fraud

In the health field, you may hear the phrase, “If you didn’t record it, it didn’t happen.” That makes having proof—well-organized documentation—crucial for risk management.

Research and Data

Patient records can also paint a more accurate picture of health in communities, states or the entire nation. Healthcare professionals can analyze anonymized data to research:

• Treatment efficacy for specific diseases or conditions at a provider- or practice-level
• Disease trends in a particular area, such as a town, city or state
• Disparities in the healthcare system for different populations

Once analyzed, this data can help inform public health policy or foster innovation in treatment options and care.

General Medical Record Documentation Guidelines

While your work may have specific requirements, some general information is seen in most documentation. Often, these are the “core six” from the National Committee for Quality Assurance (NCQA), which are:

1. List significant illnesses and medical conditions in the “problems” section.
2. Note medication allergies or adverse reactions or write “no known allergies” if applicable.
3. Include information about working diagnoses and consistent findings.
4. List treatment plans consistent with diagnoses and findings.
5. Note that there is no evidence of inappropriate risk to a patient from recommended treatment.
6. Include past medical history relevant to the visit, such as serious accidents, illnesses or operations.

You must also record other information to adhere to HIPAA guidelines, federal and state regulations or Medicare rules. These include:

• Patient name and ID number
• Biographical information, such as address, date of birth, sex and phone number
• Entry date of information on the record
• Information from the physical exam, such as height, weight, temperature and blood pressure
• Diagnoses and treatment plans
• Patient education or instructions
• Referrals or consultations requested
• Follow-up and return visits

For more information about health documents, see The American Medical Association’s Management of Medical Records resource.

Stay Updated on Health Record Best Practices With Continuing Medical Education (CME)

If you want a refresher on health record documentation requirements, CME conferences can help. Attend in-person or online for the latest medical record rules and other updates.