Accurate risk adjustment coding requires comprehensive and specific documentation in the patient’s medical record. Diagnoses must be clearly recorded with precise details, including the type, severity, and status of conditions, following ICD-10 standards. Clinical notes should support each diagnosis with relevant findings, lab results, symptoms, and treatment plans. Chronic conditions must be documented regularly, even if they are stable or controlled, as they significantly influence the patient’s risk score. Consistency in documentation across visits is crucial, with all chronic conditions needing to be updated annually during a face-to-face encounter. The medical record should also include clear documentation of treatment and management plans for each condition, along with provider signatures and dates to validate the information. This thorough documentation ensures accurate risk adjustment coding, leading to appropriate reimbursement and effective care management.