Medical record documentation is required to record pertinent facts, findings and observations about an individual's health history including past and present illnesses, examinations, tests, treatments and outcomes. The medical record chronologically documents the patient’s care and is an important element contributing to high quality care. The medical record facilitates:
- The physician’s ability and other health care professionals to evaluate and plan the patient's immediate treatment and monitor his/her health care over time;
- Communication and continuity of care among physicians and other health care professionals involved in the patient's care;
- Accurate and timely bill review and payment;
- Appropriate utilization review and quality of care evaluations;
- Collection of data that may be useful for research and education.
This would include identifying demographic information for the injured worker to image medical record documentation. An appropriately documented medical record can reduce many of the issues associated with bill processing and may serve as a legal document to verify the care provided, if necessary.
What information does BWC want and why?
Because we have an obligation to employers, they may request documentation that shows services are consistent with the coverage provided. For this reason BWC requires information to validate:
- The site of service;
- The medical necessity and appropriateness of the diagnostic and/or therapeutic services provided;
- Services provided are accurately reported;
- Services are related to the allowed claim condition.
General principles of medical record documentation
The principles of documentation listed below are applicable to all types of medical and surgical services in all settings.
- The medical record shall be complete and legible.
- The documentation of each patient encounter shall include:
- Reason for the encounter and relevant history, physical examination findings and prior diagnostic test results;
- Assessment, clinical impression or diagnosis;
- Plan for care;
- Date and legible identity of the patient and the author.
- If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.
- Past and present diagnoses along with allowed conditions should be accessible to the treating and/or consulting physician.
- Appropriate health risk factors should be identified.
- The patient's progress, response to and changes in treatment and revision of diagnosis should be documented.
- The Current Procedural Terminology(CPT®),
- Level II and Level III Healthcare Common Procedure Coding System and International Classification of Diseases (ICD) codes reported on the CMS-1500 or Service Invoice (C-19) must be supported by the documentation in the medical record.
Note: For evaluation and management (E/M) services, the nature and amount of physician work and documentation varies by type of service, place of service and the patient's status. The general principles listed above may be modified to account for these variable circumstances in providing E/M services.