Medical Documentation Standards

The primary purpose of the Decision Tree structure is to prepare medical documentation. Thus, an explanation of the accepted and mandated guidelines on medical documentation needs to be presented.

In the U.S., the guidelines for medical documentation are enforced primarily by the Health Care Financing Administration (HCFA). Although these guidelines apply only to government paid services, MedInformatix uses this standard on all medical documentation. The following discussion deals specifically with physician documentation.

All physician documentation can be categorized into two main types:

1. Evaluation and Management Documentation (Office Visit Notes)

2. Procedure Documentation

The area where significant guidelines have been established on documentation is on the Evaluation and Management side and this is type of documentation is informally known as the “Progress Note”.

Organization of an Evaluation/Management Document

• History (Subjective)

• Chief Complaints

• History of Present Illness

• Review of Systems

• Past Medical History

• Family History

• Social History

• Examination (Objective)

• Vital Signs

• Physical Exam

• Diagnostic Test Data/Interpretations

• Decision Making

• Assessment

• Plan

• Diagnostic Tests

• Pharmacological Plan

• Injections

• IV

• Procedures/Surgeries

• Referrals

• Patient Education

• Followup

Organization of Procedure Documentation

• Indications

• Consents

• ProcedureDescription

• Preparation

• Technique/Course

• Anesthesia

• Findings/Discharge Diagnosis

• Discharge Plan

• Complications

• Followup