General Documentation Tips

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 date of service on each page

Be complete and legible. Re-read the information, does it make sense.

Note the chief complaint or the reason for visit.

Detail any health risk factors.

Detail patients progress or lack thereof.

Sign note with full name and credentials.

Problem list should be updated and contain beginning and end dates for listed conditions.