Medical Record Guidance

We often get questions about what constitutes a complete medical record.  To date, there is no all-encompassing official definition, although CMS provides their requirements during a Risk Adjustment Data Validation.

For offices, groups and health plans trying to develop coding compliance policies, there hasn't been a lot of information available.  Recently, the American Health Information Management Association (AHIMA) has tackled the issue head on in Defining the Core Clinical Documentation Set for Coding Compliance.  This useful article will help anyone tasked with creating a coding compliance policy.  You can find a copy of this paper here.