Health Record Content and Documentation
Scope
This domain covers what a complete record contains and how documentation must be authored. Know the components of a history and physical (chief complaint, history of present illness, review of systems, past medical/surgical/social/family history, physical examination, and medical decision making), the hospital discharge summary, operative report, pathology and radiology reports, nursing notes, progress notes, consultation reports, and advance directives. Understand authentication requirements, timeliness standards, verbal and telephone order procedures, late entries, and addenda, and know that amendments must never obliterate the original entry - the correction is dated, timed, and signed with the reason.
Candidates also need the concepts behind documentation integrity: the record must be legible, complete, accurate, timely, and authenticated by the author; abbreviation and symbol lists limit unsafe shortcuts; and the legal health record versus the designated record set distinction matters for release of information.
Traps
A frequent trap is asking you to assign a diagnosis or procedure supported only by a nurse’s note, an order, or a patient’s statement - diagnoses must be documented by the responsible provider. Another is the rule that if it was not documented, it was not done: absent documentation cannot be inferred or coded. Retention questions require knowing that retention periods are usually set by state law, accreditation standards, and payer contracts, and that the longest applicable requirement governs. Verbal orders must be authenticated within the organization’s stated timeframe.
Worked example
A physician assistant documents “possible pneumonia” on an outpatient encounter. Because outpatient coding requires a confirmed diagnosis, query the provider or code the documented sign/symptom (e.g., cough) instead of pneumonia.