Appendix D - 1997 EM Guidelines / II_General_Principles_of_Medical_Record_Documentation

Article Overview

This article summarizes the general principles of medical record documentation used for evaluation and management services across settings. It is relevant to clinicians, coders, auditors, and compliance staff who need a high-level understanding of what documentation should capture and how it supports reported services on claims and billing records. The content focuses on broad documentation expectations, record completeness, and alignment between the medical record and reported coding.