In the latest revision of its guidelines for documenting evaluation and management (E&M) services, released in June for implementation in January 2002, the Health Care Financing Administration (HCFA) lists 10 general principles for physicians to use in medical record documentation. HCFA, which administers the Medicare and Medicaid programs, states that these apply to "all types of medical and surgical services in all settings."

These are the principles:

• The medical record should be complete and legible.

• The documentation of each patient encounter should include the chief complaint and/or reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results; assessment, clinical impression, or diagnosis; plan for care; and date and verifiable identity of the health care professional who provided the service.

• If not specifically documented, the rationale for ordering diagnostic and other ancillary services should be able to be easily inferred.

• To the greatest extent possible, past and present diagnoses and conditions, including those in the prenatal and intrapartum period that affect the newborn, should be accessible to the treating and/or consulting physician.

• Appropriate health risk factors should be identified.

• The patient’s progress, response to and changes in treatment, planned follow-up care and instructions, and diagnosis should be documented.

• The CPT and ICD-9 codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

• An addendum to a medical record should be dated the day the information is added to the record and not dated for the date the service was provided.

•  A service should be documented while it is being provided or as soon as practicable afterward in order to maintain an accurate medical record.

• Medical record confidentiality should be fully maintained consistent with the requirements of medical ethics and of law.