Provider Blog / Tips for Improving Documentation
December 5, 2025
Tips for Improving Documentation
As the end of the year approaches, it is often common to set New Year’s Resolutions. So why not make a workplace resolution to improve documentation? After all, everyone has a role in the patient’s care. Record review audits are being conducted from 2018 straight thru to 2026 and annually thereafter. While you can’t go back in time, you can start fresh for 2026!
Tips to Ensure Accuracy in Charting
Dates and Timelines: Specific dates and timelines provide important information and can affect diagnosis code assignment
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- Vague: “Follow-up office visit for recent myocardial infarction”
- Specific: Patient was discharged from Great Medical Center on 11/8/2025 after inpatient admission for acute myocardial infarction”
Specificity: Avoid vague diagnosis descriptions, i.e., “other” or “unspecified.” Describe each final diagnosis to the highest level of specificity, such as:
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- Acute, chronic, acute-on-chronic
- Current stage
- Location or site
- Controlled or uncontrolled
- Primary, secondary, recurrent, in remission
Consistency: Use caution when using EHRs that might introduce conflicting or contradictory information, i.e., Assessment states “left hemiparesis due to a previous CVA” however the neuro review of systems and detailed neuro exam are noted as normal.
Assessment and Plan: This is where the Provider compiles the medical decision-making for the encounter and documents the patient’s visit diagnoses, treatment plan, or referral and any other plans discussed for the visit. Document to the highest level of specificity for the following:
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- Status of each condition that currently exists (do not include historical) such as stable, in remission, or improved, etc.
- All comorbid or coexisting conditions that impacted patient care, treatment, or management for this visit
- Final diagnosis for all conditions, including how each condition was evaluated and managed during the visit
Supporting Documentation: The medical record should provide supporting documentation for each condition or diagnosis listed:
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- Related signs and symptoms and physical findings
- Medication lists should document the drug name, dosage with times and/or frequency, and clear linkage to the condition or conditions for which the drug has been prescribed
- Results of diagnostic testing, including the physician’s interpretation with indication of the clinical significance
- For any chronic conditions impacting patient care, treatment, and management and being followed by a different provider, supporting documentation would be a notation to that effect
Historical Versus Current
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- Do not use the descriptor “history of” to describe a current or chronic condition that is still present, active, or ongoing. In diagnosis, “history of” means a condition occurred in the past and is no longer a current problem.
Common Coding Errors Found in Recent Audits
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- Active or current cancer versus a history of. To be current or active, there needs to be supporting documentation of current treatment.
- Depression listed, however, no follow through documented, type not specified, no supporting documentation.
- CKD noted in history. Generally seen without staging noted, no supporting documentation.
- SDOH has been brought up numerous times by CMS over the past year. If the patient mentions an area of concern, there has been no follow-through noted in at least eight out of ten cases.
- Lack of supporting documentation.
- Chronic conditions are not reviewed annually.
Coding Tip Corner
Always follow the golden rule: If it’s not documented, don’t code it! Medical coding should never be assigned based solely on a diagnosis noted in the problem list, based on the following reasons:
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- Lack of Clinical Support: For a condition to be coded for a specific encounter in the medical record, the encounter must demonstrate the condition was managed, treated, monitored, and evaluated during the visit.
- Inaccuracy and Outdated Information: Problem lists often contain conditions that are resolved, historical, and are no longer relevant to the patient’s current care.
- Risk of Non–Compliance: Coding from an unsupported problem list can lead to improper billing, which may be flagged during audits as potentially fraudulent.
- Documentation Requirements: Official coding and billing guidelines from the Centers for Medicare & Medicaid Services (CMS) and authoritative bodies state that the progress note or the assessment and plan are the primary documentation sources to support a diagnosis for an encounter, not the problem list itself.
Documentation Example
An example often seen in current records is for a patient with cancer, however, there is no current treatment noted in the record.
Cancer is considered active when:
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- The patient is currently and actively being treated and managed for cancer. Scenarios demonstrating active cancer treatment/status include:
- Current chemotherapy, radiation, or anti-neoplasm drug therapy
- Current pathology revealing cancer
- A newly diagnosed patient awaiting treatment
- Affirmation of current disease management
- Refusal of therapeutic treatment by patient or watchful waiting
- The cancerous organ has been removed or partially removed, and the patient is still receiving ongoing treatment such as chemotherapy or radiation
- The patient is currently and actively being treated and managed for cancer. Scenarios demonstrating active cancer treatment/status include:
Cancer is considered historical when:
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- The cancer was successfully treated, and the patient isn’t receiving treatment.
- The cancer was excised or eradicated and there’s no evidence of recurrence and further treatment isn’t needed.
- The patient had cancer and is coming back for surveillance of recurrence.
- The patient is currently on adjuvant therapy (like Lupron or Tamoxifen) for prophylactic purposes.
The problem list can be used as a tool for the coder to prompt the provider for further documentation if a condition on the list appears to be current but is not addressed in the progress note.