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) (

  • 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?

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