CMS Clinical Template and Data Elements for Medical Record Documentation
The Centers for Medicare and Medicaid Services (CMS) has clinical templates and suggested Clinical Data Elements (CDEs) available to assist with data collection and medical record documentation. CMS suggests that IT vendors can integrate the CDEs into Electronic Health Record (EHR) systems to remind providers what they need to document.
Providers not using an EHR can print a template, fill it out, and file it in the patient’s medical record. Currently templates and CDEs are available for:
- Home health
- Glucose monitors
- Lower limb prosthesis
- Power mobility devices
Included with today’s notice is a general policy addressing client records for DMEPOS as well as an example home health medical record content policy.
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