General Medical Record Documentation Standard

Title: General Medical Record Documentation Standard
Standard #:

DC-300

Issued: 12/01/1997 Reviewed/Revision Date: 08/21/2000, 10/06/2009, 11/01/2011

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 Help & Reporting Line at (213) 740-2500 or (800) 348-7454.