1 995 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,”...