STANDARD

An appropriately documented medical record is considered a:

• Clinical Document to record the clinical care of the patient and the medical necessity of the care
• Business Document to support the organization’s billing activity
• Legal Document when needed to defend government or medical malpractice actions

It is required that USC Healthcare Professionals comply with OIG guidance which states:

1. The medical record should be complete and legible.
2. The documentation of each patient encounter should include:
   • reason for the encounter and relevant history
   • physical examination findings
   • prior diagnostic test results
   • assessment, clinical impression or diagnosis
   • plan for care
   • authenticated/signed and dated by the provider(s)

Questions regarding policies, procedures or interpretations should be directed to the USC Office of Culture, Ethics and Compliance at (323) 442-8588 or USC Report & Response at (213) 740-2500 or (800) 348-7454.