What content is required in a Medicare record?

From the Guidelines

Medicare records require accurate and relevant clinical documentation, including decision-making and care management activities, rather than just boilerplate default negative or normal findings 1.

Key Components

• Pertinent positive or negative findings from the review of systems and physical examination, rather than just a generic statement 1
• Thoughtfully written documentation that efficiently conveys findings, thought processes, decisions, and actions taken 1
• Brevity and thoughtfulness in documentation, avoiding nonstandard terminology and forced uniqueness 1
• Accurate reflection of what occurred during the patient-physician encounter, without misrepresentation of medical necessity 1

Acceptable Documentation Practices

• One-click templates and macros to generate findings from a normal physical examination or review of systems, as long as the final documentation is accurate and verified by the physician 1
• Shortcuts to bring forward other history, if verified and updated by the physician as necessary 1
• Use of structured data, which can aid clinical care and improve documentation efficiency 1

From the Research

Medicare Record Requirements

The content required in a Medicare record is not explicitly defined in a single study, but various studies provide insights into the necessary components.

• A Medicare record should include 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 2.
• The record should also include possible, probable, and rule/out diagnoses to enhance the level of complexity of medical decision-making 2.
• The use of forced entry charts can facilitate proper chart documentation and help assure compliance with Medicare's chart documentation requirements 2.
• Electronic Health Records (EHRs) can provide good predictions of adherence trajectory and may be useful for providers seeking to deploy resource-intensive interventions 3.
• The Medicare Electronic Health Record Incentive Program requires providers to perform strongly on core and menu measures, including computerized order entry, maintaining an active medication list, and documenting vital signs 4.

Electronic Health Records (EHRs)

EHRs are an essential component of a Medicare record, and their use has brought new challenges and successes.

• The Centers for Medicare and Medicaid Services (CMS) Electronic Health Records (EHR) incentive program for hospitals requires hospitals to meet specific requirements to receive incentive payments 5.
• EHRs are not necessarily equivalents to the paper chart of the 1980s, and it is essential to define what is included in the legal medical record (LMR)/designated record set to ensure accuracy 6.
• EHR data can provide good predictions of medication adherence trajectory, but claims data are highly predictive of patients in the worst adherence trajectory 3.