E/M documentation pitfalls and audit advice.

Abstract

This article examines some of the potential problems inherent in the 1995 and 1997 Federal Documentation Guidelines and goes on to give some broad advice regarding documentation of evaluation and management (E/M) services. One small area covered by the guidelines, the history of present illness (HPI), is given some attention as an example of the variability of the guidelines. The use of templates and electronic medical records (EMR) is also addressed in terms of how auditors and regulators would like to see these tools used. A section is devoted to the most important elements of medical record documentation from an auditing perspective. A do's and don'ts section covers common areas of chart deficiencies and focus.