Medical Documentation Standards

Complying With Medical Record Documentation …

https://www.hhs.gov/guidance/document/complying-medical-record-documentation-requirements-fact-sheet

Download the Guidance Document. Final. Issued by: Centers for Medicare & Medicaid Services (CMS) Issue Date: April 01, 2017. DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.

ICN909160 | CMS - Centers for Medicare & Medicaid …

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/ICN909160

Publication Description: Learn about proper medical record documentation requirements; how to provide accurate and supportive medical record documentation. …

Guidelines for Medical Record Documentation

https://www.ncqa.org/wp-content/uploads/2018/07/20180110_Guidelines_Medical_Record_Documentation.pdf

Commonly Accepted Standards for Medical Record Documentation 1. Each page in the record contains the patient’s name or ID number. 2. Personal biographical data include …

Documentation Matters Toolkit | CMS

https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Program/Education/Documentation

Standards for Joint Commission Accreditation and …

https://www.jointcommission.org/standards/

The standards review various aspects of your care delivery process, ensuring a comprehensive review of the patient care experience. The accreditation and certification …

Guidelines for Clinical Documentation …

https://www.aapc.com/blog/51598-guidelines-for-clinical-documentation-improvement/

The following Touro University California documentation guidelines, supported by institutional review board-approved research and engagement with current …

5 Best Practices for Medical Documentation - Clinical Advisor

https://www.clinicaladvisor.com/home/topics/practice-management-information-center/5-best-practices-medical-documentation/

Examples of such documentation include “Follow up in 1 month regarding change in losartan dosage and then resume routine follow-up every 3 months” or “will …

Clinical documentation | How to document …

https://onthewards.org/how-to-document-well/

Medical documentation is a document of service that has huge implications for hospital funding. Each issue that is documented is coded and then translated into …

Documentation Matters Fact Sheet for Behavioral Health …

https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Program/Education/Resource-Library/documentation-matters-fact-sheet-behavioral-health-practitioners

Documentation Description This resource is part of the Documentation Matters toolkit, which educates providers about the importance of compliance in medical …

Article - Standard Documentation Requirements for All …

https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=55426

For Medicare to provide payment, the beneficiary must meet all Medicare coverage, coding, and documentation requirements for the DMEPOS items in effect …