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) 
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.

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