Other Documentation Standards

What should be in the medical records? Here are a few Documentation Standards. If you find others that need to be here, we'd love to share.

Contents on these pages can be viewed by hovering over the icon to the left of the links with your mouse. They can also be printed.

They can also be downloaded directly, by right-clicking on the link with your mouse and opening to a new window.

American Academy of Pediatrics - E/M Documentation Guidelines

American Chiropractic Association - Commentary on CMS/PART B Clinical Documentation Guidelines

American College of Radiology - "ACR Practice Guideline for Communication of Diagnostic Imaging Findings"

California Worker's Comp (DWC) - Regulations & Fee schedules from 2005 through 2009 for various specialties:

• Ambulance, Ambulance fees
• Durable medical equipment, prosthetics, orthotics and supplies
• Inpatient hospital
• Medical-legal
• Outpatient hospital
• Pathology and clinical laboratory
• Pharmaceuticals
• Physician services

Capital Blue Cross - Practice Guidelines, 2009

Empire Blue - Medical Record Standards

M*Plan - Medical Records Documentation Standards

National Kidney Foundation - CNSW Documentation Guidelines for Dialysis & Translplant Facilities

Noridian (Medicare) -Documentation Guidelines - Amended Records

Noridian (Medicare) - Occupational Health Therapy Documentation Guidelines & Codes

Ohio Bureau of Worker's Comp - Medical Document Policy

PBSI (Pinnacle Medicare of RI) - Documentation Guidelines - Group Psychotherapy and Related Training/Educational Services

Southern Health Services - Coventry Health Plan - Guidelines for Medical Record Documentation