A Key for Evaluation and Management Documentation
Medical record documentation records pertinent facts, findings, and observations about the patient's health history services performed by the physician. According to A Resource for Residents, Practicing Physicians, and Other Health Care Professionals*, every service billed must be documented and the record should be able to show clear evidence that the service was actually performed.
Documentation in the medical record should be complete, clear, and legible. Occasionally, medical records are requested for review and from the documentation the following must be easily discernable to the reviewer:
- who is the patient
- when was the service performed
- who performed the service
- what service was performed
- reason why the service was performed
Abbreviations or acronyms are a common part of most medical documentation. Standard and accepted medical abbreviations can be found in most medical dictionaries. However, a provider's personal or a specific medical specialty's abbreviations and acronyms may not be easily deciphered. Frequently these abbreviations or acronyms are used in the history and examination components of the Evaluation and Management services. As the selection of the appropriate level of the Evaluation and Management service is based on the documentation, it is important that all information be appropriately considered. Therefore, when submitting medical records for review, a key should be included with your documentation when using non-standard abbreviations or acronyms to be certain that all information is clearly and correctly interpreted.
The following examples could be misinterpreted and not reviewed in the same context that the provider documented:
- Examination of the chest: "CVA tenderness" (costovertebral angle and not cerebrovascular accident)
- History notation of "PI" and Examination notation of "PI": (indicates Personal Injury in Chiropractic terms and Peripheral Iridectomy in ophthalmologic common abbreviations).
A key to common terms and abbreviations used in specific practices could assist the reviewer in interpreting the medical record and should leave little doubt as to what the provider documented.
*Resource: Medicare Physician Guide: A Resource for Residents, Practicing Physicians, and Other Health Care Professionals; April 2006; (Reference I: 1995 Documentation Guidelines for Evaluation and Management Services and Reference II: 1997 Documentation Guidelines for Evaluation and Management Services)
