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Documentation Matters Toolkit

Guidance for Documentation Matters Toolkit, including fact sheets, educational videos and resource guides.

Final

Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: July 15, 2020

Documentation Matters Toolkit

Providers are responsible for documenting each patient encounter completely, accurately, and on time. Because providers rely on documentation to communicate important patient information, incomplete and inaccurate documentation can result in unintended and even dangerous patient outcomes. Accurate documentation supports compliance with federal and state laws and reduces fraud, waste, and abuse.

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DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.