1995 DOCUMENTATION GUIDELINES FOR E&M SERVICES from CMS

1995 DOCUMENTATION GUIDELINESFOR EVALUATION AND MANAGEMENT SERVICES

as it relates to Risk Adjustment we can refer to page 2 of the document,

GENERAL PRINCIPLES OF MEDICAL RECORD DOCUMENTATION

3 elements to evaluative statement about the diagnosis/disease should include:
1. assessment
2. clinical impression, or diagnosis
3. plan for care

The patient's progress, response to and changes in treatment, and revision of diagnosis should be documented.

and in the section:
DOCUMENTATION OF THE COMPLEXITY OF MEDICAL DECISION MAKING

on page 12,

"For a presenting problem with an established diagnosis the record should reflect whether the problem is: a) improved, well controlled, resolving or resolved; or,
b) inadequately controlled, worsening, or failing to change as expected.
For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of a differential diagnoses or as "possible,” "probable,” or "rule out” (R/O) diagnoses.
DG: The initiation of, or changes in, treatment should be documented. Treatment includes a wide range of management options including patient instructions, nursing instructions, therapies, and medications.
DG: If referrals are made, consultations requested or advice sought, the record should indicate to whom or where the referral or consultation is made or from whom the advice is requested" [Documentation guidelines are identified by the symbol • DG.]

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnedwebguide/downloads/95docguidelines.pdf

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