DOCUMENTATION REQUIREMENTS FOR THE Health care record

Documentation and the health care record

The health care record is a legal document, and has many roles in addition to those involved in caring for a patient where documentation of the patient’s health history, health status (sickness and wellness), observations, measurements, and prognosis are recorded.

This documentation allows the record to serve as the legal record substantiating healthcare services provided to the patient. It also serves as a method of communication among healthcare providers caring for a patient and provides supporting documentation for reimbursement of services provided to a patient.

The legal health record serves as the legal business record for your practice. The roles of the legal health record are to:

Support the decisions made in a patient’s care
Support the revenue sought from third-party payers
• Document the services provided as legal testimony regarding the patient’s illness or injury, response to treatment, and caregiver decisions

This section is divided into 3 parts:

• General Documentation
• Initial Visit Documentation
• Subsequent Visit Documentation

General Documentation Requirements

A.  All health records should be accurate, complete and legible.  

B.  The patient health record must include documentation for all services performed in the office as well as all communication and correspondence from other sources regarding the patient.  

C.  All services and procedures reported must be represented by the most appropriate CPT, HCPCS and ICD codes.

D.  The patient’s health record must include documentation to support any modifier reported.

E.  ALL covered services provided and billed through HNS must be properly reported, properly documented in the health care record, must be medically necessary and consistent with the patient's chief complaint, clinical findings, diagnoses and treatment plan.  Services provided and billed through HNS should be delivered in the most  effective and cost-efficient manner.  

 

F.  Documentation in the health care record must reflect that all services provided and billed through HNS are consistent with all HNS and HNS contracted payor policies, the policies of applicable state licensing boards as well as state and federal laws. 

G.  The health care record must include written evidence that the provider obtained informed consent from each patient prior to initiating treatment.

H.  Each page of the health record must include the name of the patient.

I.  Each page of the health record must include the signature (or electronic equivalent) of the rendering provider, including the professional designation “DC”.

J.  Entries to the health record should be made during or closely following the patient encounter.

K.  Entries should be added chronologically.

L.  No entries should be erased, deleted, or “whited out”.  Corrections or changes should be made by marking a single line through the original entry.  Both the entry that is marked through AND the correction entry should be dated and initialed.

M.  Copies of any written or verbal communication and/or correspondence should be maintained in the patient’s health record and must be signed by the treating physician.  This includes, but is not limited to, consultations, test results, reports, letters, consent forms, pertinent notes from phone conversations with patients, etc.

N.  Results of all diagnostic reports must be signed and dated by the reviewing/rendering provider and must be included in the health care record.

O.  Documentation must include appropriate treatment plans for each phase of care pursued.   The patient’s health record must include S.O.A.P. notes, and review of ADLs.

P.  All health care records must include written evidence of informed consent.

Q.  If abbreviations are utilized, only standard abbreviations common to all healthcare providers should be used. – Abbreviations in the health record should be legible. The abbreviation legend should be maintained in the provider’s office.

Initial Visit Documentation

A.  The patient’s health record must include the date of service.

B.  The patient’s record must include patient and demographic information. Including:

1. The date the information is obtained from the patient

2. Patient’s full name

3. Patient’s date of birth

4. Patient’s address

5. Patient’s telephone numbers (home and work)

6. Employer information (name, address, and phone number)

7. Occupation

8. Spouse information

9. Social security number (if applicable)

10. Name of parent or guardian, if patient is a minor or incapacitated

11. Emergency contact information

12. Legible copy of patient’s current insurance card

13. Verification of Insurance Benefits form

14. If applicable, waivers for specific non-covered services provided

C.  The patient’s health record must include date history taken.

 

D.  The patient’s health record must include past history, family history, and social history (occupation, recreational interests, hobbies, use of drugs, etc.).

E.  The patient’s health record must include chief complaint(s).

F.  The patient’s health record must include onset, duration, frequency, location, and radiation of symptoms.

G.  The patient’s health record must include aggravating or relieving factors.

H.  The patient’s health record must include causation, accident, injury, or other etiology.

I.  The patient’s health record must include past and present medical or chiropractic treatment for this condition and results of that treatment.

J.  The patient’s health record must reflect any health risk factors that have been identified.

K.  The patient’s health record must include all clinical and examination findings and must include vital signs (must obtain, at a minimum, weight, pulse and blood pressure).

L.  The patient’s health record must indicate whether diagnostic tests or patient histories revealed any contraindications warranting x-rays prior to treatment.

M.  The patient’s health record must include any diagnostic studies performed.

N.  If radiographs taken, they must be consistent with the patient’s chief complaint, clinical findings and diagnoses.

O.  If radiographs taken, the patient’s health record must include a written radiographic report.

P.  The health care record should include all diagnostic impressions.

Q. The patient’s health record must include a treatment plan.

R.  The treatment plan must be consistent with the patient’s chief complaint, clinical findings, and diagnoses.

S.  The patient’s treatment plan must include recommended level of care (duration and frequency of visits).

T.  The patient’s treatment plan must include objective measures to evaluate treatment effectiveness.

U.  The patient’s treatment plan in the patient’s health record must include phases of care pursued.

V.  The patient’s treatment plan in the patient’s health record must include specific, measurable goals (both short and long term) and outcomes expected. 

Subsequent Visit Documentation

A.  Each page of the patient’s health record must include the dates services were provided.

B.  The patient’s health record must include appropriate diagnoses.

C.  The diagnoses must be consistent with the patient’s chief complaint, clinical findings, and treatment.

D.  For services billed to a HNS contracted payor, the diagnoses must be related to a neuromusculoskeletal condition.

E.  The patient’s health record must include any revision of diagnoses.

F.  The patient’s health record must include a review of the chief complaint.

G.  The patient’s health record must include significant changes in subjective complaints including, but not limited to, frequency and intensity of pain or discomfort and review of ADL deficit.

H.  The patient’s health record must include assessment of changes in clinical impression (if any) since last visit.

I.  The patient’s health record must include an examination of area involved in diagnosis.

J.  The patient’s health record must include a written, signed radiology report for any repeat or subsequent x-rays.

K.  The patient’s health record must include documentation to demonstrate any subluxations and must include the location and specific segments or regions manipulated.

L.  The patient’s health record must include the medical necessity for all CMT's, modalities and/or therapies performed, and if time based, the actual time therapy was performed.

M.  The patient’s health record must include patient education and/or home recommendations.

N.  The patient’s health record must include any relevant information regarding DME, and the medical necessity for the DME.

O.  The patient’s health record must include patient’s progress as it relates to treatment plan.

P.  The patient’s health record must include any changes to current treatment plan and rationale for those changes.

Q.  If applicable, the patient’s health record should include notes regarding patient compliance.

R.  The patient’s health record must include response to treatment, any changes in treatment and the rationale for the change.

S.  The patient’s health record must include an evaluation of treatment effectiveness.

T.  The patient’s health record must include prognosis, final diagnoses and discharge date.

U.  The patient’s health record should include patient status on discharge and must include summary upon discharge to determine final outcome of treatment rendered.

V.  The patient’s record should indicate when maximum medical improvement has been reached, consistent with N.C. Board of Examiner Practice Guides.

W.  The patient’s record must indicate if care if provided is maintenance/supportive care.