Basics of Medical Documentation for Nephrologists Practicing in the United States

Elvira O Gosmanova, Aidar R Go

Abstract

As nephrologists we spend a considerable amount of time mastering the art of diagnosing and treating  kidney diseases, which is paramount for improving health of our patients. However, it is equally important to have a solid understanding of basics of medical documentation and how it applies to a nephrology  subspecialty in order to communicate with other providers and auditors, and receive appropriate  reimbursement for rendered services. In addition, the knowledge of medical documentation helps to avoid  over performing and documenting unnecessary findings, and allows to concentrate on a key elements  supporting medical decision making, thereby, contributing to overall efficiency. This paper overviews the  structure of medial documentation and its key sections such as History, Physical examination, and Medical decision making. We also review documentation requirements for different types and levels of medical  encounters routinely performed by nephrologists, including  documentation for dialysis encounters.