Subscribe to eNews Contact us

Checklist: Skilled nursing facility (SNF) documentation

This checklist is intended to provide Healthcare providers with a reference to use when responding to medical documentation requests for skilled nursing facility (SNF) services. Healthcare providers retain responsibility to submit complete and accurate documentation.

Check Documentation description
  Please submit a mandatory advanced beneficiary notice (ABN) if issued
  Documentation is complete, legible, signed and dated by the physician or clinician
 

Verify SNF benefit days available

  • If waiver(s) are to be appended confirm they were billed correctly in FISS
 

Physician / Provider Documentation

  • Physician’s orders specifying need for SNF care with signature and date
  • History and physical
  • Admission assessment
  • Physician’s certification and recertification for skilled care with signature and date
    • If delayed Cert / recert if warranted; with reason for delayed cert, cert period, and physician / clinician signature
  • Physician’s orders physician / non-physician practitioner (NPP) order / intent signed and dated
  • Physician’s progress notes
  Medical records for 30 days prior to each assessment reference date (ARD)
 

Nursing Documentation

  • Nurse's admission assessment signed and dated
  • Nurse's notes
  • Medication Administration Record Sheet (MARS) signed and dated
  • Treatment records
 

Minimum Data Set (MDS)

  • Initial Care Plan signatures and dates by the team
  • Assessment and re-assessments, care plan revisions in MDS
  • Documentation to fully support the information on the MDS
  Medication and treatment records
 

Rehabilitation Documentation

  • Initial therapy evaluation / treatment plan with G codes, signatures and dates
  • Therapy evaluation / re-evaluation
  • Therapy progress notes and medical necessity for continued rehabilitation services
  • Treatment logs to identify therapy minutes
  • Signatures / credentials of professionals providing services
 

Hospital records to support the qualifying stay that includes:

  • Transfer sheet
  • History and physical
  • Discharge summary
  • Surgical report
  • Pertinent medication and fluid administration documents that validate MDS entries
  • Documentation that skilled services are reasonable and necessary

 

Disclaimer

This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or the CMS documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.