Basic checklist for E/M documentation

The following checklist appeared in the April, 2008 issue of Managed Care Contracting & Reimbursement Advisor (I'm on the editorial board) (www.hcpro.com):

• Is the chief complaint clearly stated?
• Are the elements of the history of present illness documented?
• If using an earlier review of systems (ROS), is the date and location documented in the current note?
• If ancillary staff members took the ROS and/or past, family, and social history, is there a note supplementing or confirming information recorded by others?
• Is the level of exam performed supported by the nature of the presenting illness?
• Are the organ systems examined clearly identified?
• If abnormalities are found, are they described in the documentation?
• For medical decision-making, are the number of possible diagnoses clearly identified?
• For an existing problem, does the documentation indicate whether the condition is improving, worsening, responding to medication, etc.?
• Does the diagnosis recorded in the chart support the need for ancillary services ordered?
• Are the risks clearly identified?
• Have the CPT and ICD-9 coding guidelines been used in assigning the code(s)?
• If time is the determining factor, is time documented in the record?
• Is the record legible, including the date and identity of the provider?