Medical documentation and checklists

Medical record documentation is required to record pertinent facts, findings and observations about an individual's health history including past and present illnesses, examinations, tests, treatments and outcomes. Find tips, tools and resources for the documentation of services provided to Medicare patients below. Use the documentation checklists to ensure you have met requirements based on specific services required when you receive an additional documentation request from Medicare.

Level of business	Article title
A/B	Importance of documentation
A/B	Medical Documentation: Amendments, Corrections, and Delayed Entries
A/B	Medicare Learning Network (MLN) Fact Sheet - Complying with Medical Record Documentation Requirements (ICN909160)
A/B	MLN Fact Sheet - Complying with Medicare Signature Requirements (ICN 905364)
A	How to Correctly Submit Additional Documentation Requests (ADR)
B	How to Correctly Submit Additional Documentation Requests (ADR)
A/B	Medical Review Fax Process for Paperwork (PWK) Segment
A	Part A Documentation Checklists
B	Part B Documentation Checklists
A/B	Reminder - Submission of Medical Record Documentation
A/B	CMS Additional Documentation Request

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Last modified: 12/14/2023

Person(s) with Medicare