Clinical documentation, made clear
Standards, templates, and job aids to help providers write accurate, timely, and complete clinical notes.
Template site
All content here is sample data for layout and design review.
Find what you need
- 4 standards
Documentation standards
Timeliness, specificity, medication reconciliation, and copy-forward guidance.
Go to section about Documentation standards - 4 templates
Note templates
Copy-ready layouts for H&P, progress, discharge, and consult notes.
Go to section about Note templates - 3 checklists
Quick reference
Checklists and do-not-use lists for use at the point of care.
Go to section about Quick reference - Learning
Training and job aids
Modules, webinars, and one-page aids for providers and coders.
Go to section about Training and job aids - Reference
Policy and regulations
Policies, directives, and regulatory references that govern documentation.
Go to section about Policy and regulations - Help
Frequently asked questions
Short answers to common documentation questions.
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Recent updates
Updated timeliness standard
Clarified timeframes for outpatient encounter notes.
New medication reconciliation guidance
Added transition-of-care checkpoints.
Telehealth checklist released
New quick reference for virtual visits.