Documentation in the medical record serves many purposes: communication among healthcare professionals, evidence of patient care, and justification for provider claims.
Although these three aspects of documentation are intertwined, the first two prevent physicians from paying settlements involving malpractice allegations, while the last one assists in obtaining appropriate reimbursement for services rendered. This is the first of a three-part series that will focus on claim reporting and outline the documentation guidelines set forth by the Centers for Medicare and Medicaid Services (CMS) in conjunction with the American Medical Association (AMA).
1995, 1997 Guidelines
Two sets of documentation guidelines are in place, referred to as the 1995 and 1997 guidelines. Increased criticism of the ambiguity in the 1995 guidelines from auditors and providers inspired development of the 1997 guidelines.
While the 1997 guidelines were intended to create a more objective and unified approach to documentation, the level of specificity required brought criticism and frustration. But while the physician community balked, most auditors praised these efforts.
To satisfy all parties and allow physicians to document as they prefer, both sets of guidelines remain. Physicians can document according to either style, and auditors are obligated to review provider records against both sets of guidelines, selecting the final visit level with the set that best supports provider documentation.
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Elements of History
Chief complaint (CC): The CC is the reason for the visit as stated in the patient’s own words. This must be present for each encounter, and should reference a specific condition or complaint (e.g., patient complains of abdominal pain).
History of present illness (HPI): This is a description of the present illness as it developed. It is typically formatted and documented with reference to location, quality, severity, timing, context, modifying factors, and associated signs/symptoms as related to the chief complaint. The HPI may be classified as brief (a comment on fewer than HPI elements) or extended (a comment on more than four HPI elements). Sample documentation of an extended HPI is: “The patient has intermittent (duration), sharp (quality) pain in the right upper quadrant (location) without associated nausea, vomiting, or diarrhea (associated signs/symptoms).”
The 1997 guidelines offer an alternate format for documenting the HPI. In contrast to the standard method above, the physician may list and status the patient’s chronic or inactive conditions. An extended HPI consists of the status of at least three chronic or inactive conditions (e.g., “Diabetes controlled by oral medication; extrinsic asthma without acute exacerbation in past six months; hypertension stable with pressures ranging from 130-140/80-90”). Failing to document the status negates the opportunity for the physician to receive HPI credit. Instead, he will receive credit for a past medical history.