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Checklist: Skilled nursing facility (SNF) documentation

This checklist is intended to provide Healthcare providers with a reference to use when responding to medical documentation requests for skilled nursing facility (SNF) services. Healthcare providers retain responsibility to submit complete and accurate documentation.

Check	Documentation description
	Please submit a mandatory advanced beneficiary notice (ABN) if issued
	Documentation is complete, legible, signed and dated by the physician or clinician
	Verify SNF benefit days available If waiver(s) are to be appended confirm they were billed correctly in FISS
	Physician/Provider documentation Physician’s orders specifying need for SNF care with signature and date History and physical Admission assessment Physician’s certification and recertification for skilled care with signature and date If delayed Cert/recert if warranted; with reason for delayed cert, cert period, and physician/clinician signature Physician’s orders physician/non-physician practitioner (NPP) order/intent signed and dated Physician’s progress notes
	Medical records for 30 days prior to each assessment reference date (ARD)
	Nursing Documentation Nurse's admission assessment signed and dated Nurse's notes Medication administration record sheet (MARS) signed and dated Treatment records
	Minimum data set (MDS) Initial Care Plan signatures and dates by the team Assessment and re-assessments, care plan revisions in MDS Documentation to fully support the information on the MDS
	Medication and treatment records
	Rehabilitation documentation Initial therapy evaluation/treatment plan with G codes, signatures and dates Therapy evaluation/re-evaluation Therapy progress notes and medical necessity for continued rehabilitation services Treatment logs to identify therapy minutes Signatures/credentials of professionals providing services
	Hospital records to support the qualifying stay that includes: Transfer sheet History and physical Discharge summary Surgical report Pertinent medication and fluid administration documents that validate MDS entries Documentation that skilled services are reasonable and necessary

Disclaimer

This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or CMS documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.

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