October 28, 2025
Accurate and complete medical record documentation helps establish a comprehensive record of your patients’ health status. Important elements of complete documentation include an assessment and treatment plan.
The assessment provides a written description of the interpretation of subjective and objective information you use to diagnose a condition. The treatment plan should be structured to include treatment details and strategies for managing the conditions assessed. The medical decision-making process culminates in a thoroughly documented treatment plan that supports quality and continuity of care by providing a record of the treatments used to reach the expected outcomes.
| Plan elements | Plan documentation examples | |
| MedicationsReferral for treatment or consultation Surgery and other therapiesOrdering additional testingManagement plan Care coordinationPatient educationFollow-up instructionsContinuation of monitoring | Type 2 diabetes mellitus – Continue glimepiride 4 mg twice daily, Trulicity .75 mg/5 ml subcutaneous once a week.Peripheral artery disease with gangrene – Referral for excisional debridement.Morbid obesity – Provided patient with additional nutrition and exercise educational materials, revise home care plan to include a low-fat diet, no alcohol. Follow up in six weeks.Pulmonary edema with heart failure – Refill carvedilol CR 40 mg qd, #30, two refills. Furosemide 40 mg bid, #60. | |
| Ensure complete and accurate documentation by providing a treatment plan for each condition assessed. | ||
Cigna Healthcare® Medicare Advantage is becoming HealthSpringSM. Our new benefit plans will be rolled out under the HealthSpring name during the 2025 annual enrollment period. Starting in January 2026, you will begin seeing patients with HealthSpring benefit coverage. Learn more.
Please let us know what you think of the Provider Newsroom information and news.
Contact Us
