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Other Documentation Standards


This page reviewed and updated 11/8/2015

American Academy of Pediatrics (AAFP) - E/M Documentation Guidelines. Very nice information here.

American Chiropractic Association - Clinical Documentation Guidelines, which is based on CMS.

American College of Emergency Physicians (ACEP) - Nice collection of documentation information in short, easy to read formats.

American College of Radiology (ACR) - Practice Parameters for Documentation and Reporting

American Physical Therapy Association (APTA) - Documentation Guidelines. Not entirely certain if this information is updated, but it seems that there are a lot of tools here. Worth taking a look.

American Society of Anesthesiologists (ASA) - Practice Management tools and documentation guidelines.

Blue Cross Blue Shield of Kansas - This is a brief overview of what is expected from Chiropractic providers. 4/2015

Blue Cross Blue Shield of Kansas - This is a more in-depth presentation of what is required from Chiropractic providers.

Medical Mutual - Checklist: Chronic Pain Management Patient Documentation – Initial Assessment. These are elements that should be noted in the patient's initial exam. This isn't dated, but likely the information hasn't changed that much. If/when in doubt, ask the carrier.

National Committee for Quality Assurance (NCQA)Guidelines for Medical Record Documentation. This isn't dated.

National Committee for Quality Assurance (NCQA)Guidelines for Treatment Record Documentation. This isn't dated.

Noridian (Medicare) -Documentation Guidelines - Amended Medical Records: Addendum, Late Entry, Corrections and False Documentation.

Ohio Bureau of Worker's Comp - Medical Document Policy