What is required for proper E/M documentation regarding assessment and plan?

What is required for proper E/M documentation regarding assessment and plan?

• A. A vague statement is enough
• B. A clear assessment and plan must be documented
• C. Only the plan is needed
• D. The assessment can be omitted if the patient is stable

Answer: (B)

Proper E/M documentation requires a clear assessment and plan for the encounter. The assessment identifies the active problems or diagnoses you addressed and concisely states the patient’s current status. The plan then lays out the management for each problem—what you will do next, including treatments, tests or referrals, patient education, and follow-up instructions. This pairing shows exactly why decisions were made and what will be done, which supports the level of service billed and ensures continuity of care. A vague statement won’t convey the patient’s problems or the rationale, and the plan alone doesn’t demonstrate what problems are being managed and how. Even when a patient is stable, you still need both a documented assessment and a plan for each problem addressed, organized so the reasoning and actions are clear.

Proper E/M documentation requires a clear assessment and plan for the encounter. The assessment identifies the active problems or diagnoses you addressed and concisely states the patient’s current status. The plan then lays out the management for each problem—what you will do next, including treatments, tests or referrals, patient education, and follow-up instructions. This pairing shows exactly why decisions were made and what will be done, which supports the level of service billed and ensures continuity of care. A vague statement won’t convey the patient’s problems or the rationale, and the plan alone doesn’t demonstrate what problems are being managed and how. Even when a patient is stable, you still need both a documented assessment and a plan for each problem addressed, organized so the reasoning and actions are clear.