Complete and Accurate Medical Record Documentation and Coding Critical to Patient Care

Date Issued: 4/4/2014

Clear and complete clinical documentation is the foundation of every patient's health record. It significantly impacts patient care, coordination, coding, billing and compliance. It is also: 

  • The key determinant of the quality of care a patient received
  • The primary tool for clinicians to communicate about a patient
  • Evidence that the care billed for was rendered to the patient
  • Data we rely on for strategic planning, internal research and identification of case, care or disease management opportunities

Accurate coding translates your clinical documentation into uniform diagnostic and procedural data sets. The better the documentation, the more we can help ensure the best outcomes for your patients – our members.


For more information, view the Centers for Medicare & Medicaid Services' Evaluation and Management Services Guide.