Keys To Keeping Good Medical Records

Medical records are an important part of any medical practice.  Keeping good records is essential in avoiding an audit or possibly not getting payment from an insurance company.  Several auditing groups include, licensing boards, payers, litigants, accreditation organizations, each one is looking for specific things in the documentation.  Licensing boards want to find out if the doctor acted within his or her scope of practice or if they were grossly negligent.  Payers want to determine if a claim is justified for reimbursement.  Litigants want to know whether a breach happened during care.  Accreditation organizations want to determine if their standards and elements of performance have been met by the doctor.

These are some general requirements for documentation.

  1. Medical Records should be complete and are legible.
  2. Documentation of each patient that is being seen should include a reason for the visit and a history that is relevant to the complaint, physical examination findings and any prior diagnostic test results, a full assessment and clinical impression and diagnosis, a plan for care and date the record along with signature of attending physician, nurse etc.
  3. Reason for ordering tests.  If this is not recorded, it can be easily proved that it was not necessary.
  4. Past and present diagnoses whether it be from the patient or other past office visits from other physicians.
  5. Appropriate health risk factors should be identified and noted.
  6. Patient’s progress, response to changes in treatment, and a change of diagnosis should be clearly documented.
  7. The CPT and ICD-9 codes reported on the insurance claim form should always be supported by the documentation in the medical record.

Meeting the standard of care medical records must:

  1. Document any details regarding a patient’s history during the exam
  2. Document referrals
  3. Document refusals of treatment and the reason the patient has refused treatment
  4. Document that the physician has clearly reviewed the possible consequences of refusing a specified treatment to the patient
  5. Document encouragement of the physician of healthcare maintenance and risk reduction (example: weight loss or smoking)
  6. Document advice that has been given to the patient (example: pink eye can spread to others in the family)
  7. Document patient noncompliance with treatment regimen or referral, including the patient’s reason for not complying and advice to the patient about the risk of failing to take the advice given.

Good medical record keeping is an important part of good business.  The consequences of errors can result in a denial of payment, audit, loss of contracts, accreditation or possible lawsuit brought on by a patient.  It may take longer to do but in the end it benefits you, your practice and most important of all your patients.

Marina Hall is a Certified Medical Reimbursement Specialist (CMRS) and founder of MariAnn Medical Billing Service. To read a full “Interview with Marina Hall” visit her website at

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