Principles of medical record documentation

The following is an excerpt from a brochure titled "Principles of Medical Record Documentation" developed jointly by representatives of the American Health Information Management Association, the American Hospital Association, the American Managed Care and Review Association, the American Medical Association, the American Medical Peer Review Association, the Blue Cross and Blue Shield Association, and the Health Insurance Association of America. Although their joint development of this brochure is not intended to imply either endorsement of, or opposition to, specific documentation requirements, all seven groups share the belief that the fundamental reason to maintain an adequate medical record is its contribution to the high quality of medical care.

Published by Journal of AHIMA, 1992. The guideline itself is at the source linked here.

pubmed.ncbi.nlm.nih.gov/10120161/