Medical Record Documentation Policy

ICN909160 | CMS - Centers for Medicare

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

ICN909160 Date 2021-01 Topic Provider Compliance Title Complying With Medical Record Documentation Requirements Format Fact Sheet ICN: 909160 Publication Description: Learn about proper medical record documentation requirements; how to provide accurate and supportive medical record documentation. Downloads

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 …

Subject Medical Record Documentation Standards …

https://www.hopkinsmedicine.org/johns_hopkins_healthcare/downloads/all_plans/cor_026_med_rec_documentation_policy_2017.pdf

POLICY: It is the policy of Johns Hopkins HealthCare LLC (JHHC) to ensure that Plan Members’ medical record documentation is maintained in a manner that is current, …

Documentation Matters Toolkit | CMS

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

Guidelines for Medical Record Documentation

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

All entries in the medical record contain the author’s identification. Author identification may be a handwritten signature, unique electronic identifier or initials. 4. All entries are dated. …