Meaning of the "Actual clinical note for the face to face encounter"
Published 11/05/2018
A clinical note has specific classes of information. The "actual clinical note for the face-to-face (F2F) encounter," required for compliant home health physician certifications, is no exception. These classes of information are demonstrated in the four examples published in the CMS MLN Matters® Number SE1436 (PDF, 366 KB).
| Chief Complaint (CC) |
| History of Present Illness (HPI) |
| Review of Systems (ROS) |
| Vital Signs (Vitals) |
| Temperature (Temp) |
| Heart Rate (HR) |
| Respiratory Rate (RR) |
| Blood Pressure (BP) |
| Physical Examination (PE) |
| Assessment |
| Plan |
| Discharge Condition |
| Follow up |
While not every class of information has to be included in the clinical note in order to meet the requirement, a compliant "actual clinical note" would contain a combination of some of the classes of information listed above.