Documentation standards
Expectations and best practices for complete, accurate, and timely clinical documentation.
- All providers
Timeliness of clinical notes
When each note type must be started, completed, and signed.
Read standard about Timeliness of clinical notes - Providers, nursing, pharmacy
Problem list and medication reconciliation
Keep the problem list current and reconcile medications at every transition.
Read standard about Problem list and medication reconciliation - Providers, coders, CDI specialists
Medical necessity and diagnostic specificity
Document the clinical picture so diagnoses and services are supported.
Read standard about Medical necessity and diagnostic specificity - All providers
Copy-forward and template use
Use copy-forward and templates responsibly to keep notes accurate.
Read standard about Copy-forward and template use