What medical record documentation is expected for the initial preventive physical exam?
The CMS states that E/M services should be documented according to the 1997 or 1995 documentation guidelines. The agency requires that screening tools used, ECG documentation, referrals and a written plan for the beneficary be included in the medical record, noting that the forms and methods should mirror those used in typical practice. The agency believes these requirements do not impose an additional burden.
