title: Compliance with Medicare's chart documentation requirements in evaluation and management (E/M) coding.
abstract: 1. Use of forced entry charts facilitates proper chart documentation and helps assure compliance with Medicare's chart documentation requirements. 2. Nurses and technicians are responsible for up to two-thirds of the required chart documentation in the patient's record. 3. Performance and documentation are not synonymous. There must be a meticulous written record of what was performed as well as negative and positive findings for both the history and the examination portions of the exam. Recording possible, probable, and rule/out diagnoses enhances the level of complexity of medical decision-making.
authors: University of Medicine and Dentristry of New Jersey-Robert Wood Johnson Medical School at Camden, USA.
authors: R L
authors: RL
authors: Asbell
mesh_terms: D000043:Abstracting and Indexing; D004282:Documentation / Q000592:standards*; D005568:Forms and Records Control; D006801:Humans; D008487:Medical History Taking / Q000592:standards; D008499:Medical Records / Q000592:standards*; D006278:Medicare; D009885:Ophthalmology / Q000592:standards; D010808:Physical Examination / Q000592:standards; D012051:Reimbursement Mechanisms; D014481:United States