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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.

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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