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Printed Date: 9/22/2015
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).
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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Last Updated: 10/04/2017