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.