The principles of documentation listed below are applicable to all types of medical and surgical services in all settings. GENERAL PRINCIPLES OF MEDICAL RECORD DOCUMENTATION that services provided have been accurately reported.the medical necessity and appropriateness of the diagnostic and/or therapeutic services provided and/or.They may request information to validate: collection of data that may be useful for research and education.Īn appropriately documented medical record can reduce many of the "hassles" associated with claims processing and may serve as a legal document to verify the care provided, if necessary.īecause payers have a contractual obligation to enrollees, they may require reasonable documentation that services are consistent with the insurance coverage provided.appropriate utilization review and quality of care evaluations and.accurate and timely claims review and payment.communication and continuity of care among physicians and other healthcare professionals involved in the patient's care.
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