Commonly accepted standards for medical record documentation 1 each page in the record contains the patients name or id number 2 personal biographical data include the address employer home and work telephone numbers and marital status 3 all entries in the medical record contain the authors identification. Medical records documentation title medical records documentation date 2014 12 01 providers should submit adequate documentation to ensure that claims are supported as billed for more information please refer to complying with medical record documentation requirements fact sheet . Documentation of medical records overview what is documentation and why is it important o medical record documentation is required to record pertinent facts findings and observations about a veterans health history including past and present illnesses examinations tests treatments and outcomes. Identifies a claim as part of the sample it requests via a faxed or mailed letter the associated medical records and other pertinent documentation from the provider or supplier who submitted the claim if there is no response to the request for medical records the cert may also make a telephone call to solicit the documentation
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