053-10 Wyo. Code R. § 10-20
Claims for medical services provided to an employee for a compensable injury, and any associated fees charged by professionals, will be denied if they fail to comply with the following standards for content of medical records:
(i) If handwritten, medical notes must be legible t anyone reading them,
(ii) If handwritten notes are illegible, medical notes must be typewritten,
(iii) Medical notes must include date of patient visit,
(iv) Medical notes must specify the reason for the encounter/visit and be described using the patient's own words,
(v) Medical notes must include a history and physical exam focused relative to patient's complaint to include a description of the findings of the examine relating to the reason for the complaint.
(vi) Medical notes must specify the diagnosis relative to the patient presenting complaint,
(vii) Medical notes must delineate a course of treatment consistent with the diagnosis,
(viii) The studies ordered of the patient must pertain to the complaint being addressed,
(ix) Medical notes must delineate the education instruction to the patient,
(x) Medical notes must contain an indication of the specifics of the follow-up care plan and include return-to-work expectations.
053-10 Wyo. Code R. § 10-20
Amended, Eff. 8/24/2017.