This blog covers general documentation tips for patient charts. Physicians should always document the status of each diagnosis using descriptive words such as: stable on meds, controlled by diet, improving, acute, chronic, worsening, etc. Be sure to include a treatment plan using descriptive words such as: continue, increase, decrease, "name of medication", refer to ______. Using a brief statement for each diagnosis would be optimal as well as referring to medication name and the reason the patient is taking it. History of means the condition no longer exists. There are appropriate codes to indicate this information. Medical Assistants can great assist the physician by checking the last time the patient had their lab work completed, as well as documenting the patients weight and making sure the BMI is calculated. BMI is currently an HCC code, we call it a buddy code as two codes are needed. Principles of Documentation Include patient name, DOB, and