General
Medicare Charting Guidelines for SNFs + A Helpful Checklist
Written by
ExaCare
Published on
May 16, 2025
When Medicare reviews your SNF documentation, it isn’t just checking boxes. It’s looking for proof.
They want proof that your care was skilled, medically necessary, and well-documented from day one. If that proof is missing or incomplete, even strong clinical care can result in denied claims.
Following clear Medicare charting guidelines for SNF facilities is critical to maintaining compliance, securing reimbursement, and avoiding costly denials. In this article, we’ll cover what Medicare expects in SNF documentation and a checklist to help keep you compliant.
Why Medicare charting guidelines matter
Medicare decisions hinge on documentation. It’s how care teams show that services were necessary, skilled, and delivered in full. In 2025, with CMS increasing SNF payments by 4.2%, the pressure is higher for facilities to back every claim with accurate, timely records.
Medicare’s role in SNF coverage and reimbursement
Medicare is the primary payer for short-term skilled nursing care after a qualifying hospital stay. Facilities can receive reimbursement for up to 100 days per benefit period — but only if the medical record shows a continuing need for skilled services.
That includes nursing interventions, therapy, and other care that requires clinical oversight. Each entry must demonstrate clinical justification, not just the service provided. It’s the difference between being paid and being flagged for review.
To learn about this criteria, see our guide on how many days Medicare covers skilled nursing care.
Impact on audits, payment, and compliance
When CMS audits a claim, the medical record becomes the core evidence. Reviewers assess whether the documentation supports the billed services and reflects medical necessity. Gaps or inconsistencies often trigger denials, overpayment requests, or financial penalties.
Charting that’s clear, consistent, and complete strengthens your position during audits and protects your revenue cycle.
Documentation as a legal record of care
Every chart also serves as a legal document. It must capture what was done, when, why, and according to whose orders. Surveyors and regulators use these records to assess compliance with care standards, resident rights, and quality measures.
Solid documentation anchors accountability across your entire operation.
Medicare charting guidelines for SNF documentation
The official Medicare guidelines for SNF documentation outline what must be recorded daily, periodically, and at major care milestones like admission and discharge.
Every Medicare- and Medicaid-certified SNF is expected to maintain clinical records that are complete, organized, and easily accessible. These are the official evidence Medicare uses to validate skilled care and issue payments.
The foundation for these rules is laid out in Chapter 8 of the Medicare Benefit Policy Manual, alongside updated guidance in the 2025 SNF PPS Final Rule.
A key piece of compliance is the Resident Assessment Instrument (RAI), which includes the MDS 3.0 and Care Area Assessments (CAAs). These tools form the backbone of every resident’s care plan, and they must be completed and maintained according to CMS timelines.
What needs to be charted daily vs. periodically
Some documentation tasks need to happen every shift. Others follow specific timelines based on regulation or changes in the resident’s condition.
Daily documentation includes:
Nursing notes with ADLs, vitals, and interventions
Therapy logs for each session
Medication administration records (MAR/TARs)
Notations of changes in condition, including incidents or new symptoms
Periodic documentation includes:
Initial assessments (within 5 days of admission)
Care plans, updated quarterly or after a significant change
Progress notes, typically weekly or per facility policy
Physician visits, required at least every 30 days for the first 90 days, then every 60 days
Discharge summaries, prepared at the end of Medicare Part A coverage
Key documentation types and expectations
Accurate documentation in key areas forms the backbone of Medicare compliance. Every resident’s record should start with an initial assessment completed within five days of admission, setting the foundation for an individualized care plan.
That care plan must be built with input from the full interdisciplinary team and updated regularly to reflect any changes in the resident’s condition. Progress notes should tell a clear, factual story about the resident’s skilled needs, responses to treatment, and any shifts in status — without relying on vague or subjective language.
When a Medicare Part A stay ends, a detailed discharge summary ties everything together, capturing the care provided, the outcomes achieved, and any follow-up needs to support a safe transition.
5-step skilled nursing charting checklist
A skilled nursing charting checklist can help facilities ensure they meet Medicare’s expectations for daily notes, therapy tracking, medication administration, and more.
The details you capture (and how consistently you capture them) determine whether Medicare sees your care as skilled and necessary.
ADL documentation and therapy tracking
Certified Nursing Assistants (CNAs) must log ADLs consistently using flow sheets or digital tools, and those entries must align with how MDS items are coded. Therapy teams need daily notes for every treatment day, with detailed minutes, progress reports, and discharge summaries that justify ongoing skilled services.
Daily nursing notes and shift summaries
Each shift should include summaries of the resident’s status, any interventions provided, and changes in condition. These notes also capture vital signs, pain assessments, and incidents such as falls or refusals of care.
Physician visits and orders
Physicians must complete an initial face-to-face visit within 30 days of admission and follow-up visits at federally defined intervals. Orders must be clear, signed, and include rationale for skilled services—not just a list of medications or treatments.
Changes in condition
When a resident experiences new symptoms, falls, or any notable change in baseline, it needs to be documented in detail. That includes what happened, when, what actions were taken, and how the resident responded.
Medications and treatment administration
MAR and TAR forms must be completed in full, time, dose, route, and staff signature. Missed doses or refusals should always be documented with an explanation and follow-up plan.
Common charting mistakes that lead to denials
Even strong clinical care can fall apart on paper if documentation isn’t handled carefully. Certain mistakes show up repeatedly during Medicare audits, and they’re often what stand between a facility and a paid claim.
One of the biggest red flags is copy-paste charting or vague, templated language. Entries need to be specific, resident-centered, and tied to the skilled services being provided. Generic notes raise doubts about the necessity and individuality of care.
Timing matters just as much. Late or missing documentation can lead auditors to question the validity of the record, especially if it looks like notes were added after the fact. Recording care in real time (or as close to it as possible) helps protect the integrity of the medical record.
Another common issue is inconsistency between disciplines. If nursing, therapy, and dietary notes don’t align. For example, if nursing documents decline while therapy records steady improvement, it invites scrutiny and potential denials.
Finally, even highly skilled interventions can’t support reimbursement if they aren't clearly documented. In Medicare’s eyes, if it’s not written down, it didn’t happen.
Skilled services must be charted fully and accurately to demonstrate medical necessity.
SNF documentation requirements by role
Strong documentation is a team responsibility. Each staff member plays a critical role in building a complete and defensible medical record:
Nursing staff must document daily notes that clearly capture the resident’s status, all interventions performed, and any observed outcomes, along with consistent tracking of ADLs, vital signs, incidents, and changes in condition that could affect care plans.
Therapists are required to maintain detailed records for each resident, including an initial evaluation, daily treatment notes, progress reports, and discharge summaries that accurately describe the type, frequency, and duration of therapy, as well as the resident’s progress toward goals.
MDS coordinators are responsible for completing accurate and timely MDS assessments by gathering and validating information across disciplines, ensuring consistency between nursing, therapy, and other documentation sources.
Physicians and nurse practitioners must conduct and document a comprehensive face-to-face evaluation within the first 30 days of admission and complete follow-up visits at required intervals, providing clear documentation of clinical assessments, signed orders, and certifications or recertifications of the resident’s skilled need.
Frequently asked questions
What’s the risk of incomplete SNF charting?
Incomplete or inconsistent documentation can lead to serious consequences, including denied Medicare payments, recoupment of funds already paid, survey citations, and even civil monetary penalties. Facilities that fall short on documentation standards risk both financial and compliance setbacks.
How often should SNF documentation be updated?
SNF documentation should be updated daily for nursing and therapy notes, and whenever there is a significant change in the resident’s condition. Formal assessments must be completed at admission, discharge, quarterly, and as needed based on clinical changes. Regular updates ensure the medical record accurately reflects the resident’s current needs.
Are nursing notes required daily in a SNF?
Yes, nursing notes must be completed daily in a skilled nursing facility. Daily documentation supports ongoing skilled need, tracks changes in the resident’s status, and demonstrates compliance with Medicare’s documentation requirements.
What happens if documentation doesn’t support skilled need?
If documentation fails to show that skilled services were necessary and provided, Medicare can deny the claim entirely.
Facilities may then become responsible for repaying funds received for that care, even if services were delivered appropriately. Clear, detailed charting is essential to prove skilled need for every day billed. Learn more about billing rules in our guide on how to bill Medicare as a provider.
Can Medicare deny claims based on poor charting?
Yes, Medicare frequently denies claims when documentation is vague, missing, or fails to directly support the skilled services billed. Strong documentation is critical to linking the clinical story to the services reimbursed.
How can software help with documentation compliance?
These tools help facilities maintain complete, organized, and defensible medical records that meet Medicare standards. Modern electronic health record (EHR) systems and platforms like ExaCare can significantly improve documentation compliance by centralizing records, reducing manual errors, and streamlining audit preparation.
How ExaCare supports documentation compliance
To satisfy Medicare charting guidelines for SNFs, strong documentation starts at admission.
ExaCare is built to support it from the first referral onward. By connecting admissions workflows directly to care planning, ExaCare ensures critical clinical and financial data flows into the medical record without manual gaps or delays.
Audit trails built into the platform track data from hospital referral packets through the entire intake process. This makes it easy for facilities to verify information sources during audits and strengthen the defensibility of their charts.
ExaCare also helps reduce denials and billing delays by improving the speed and quality of admissions decisions. Facilities can respond to referrals faster, admit residents more efficiently, and ensure documentation consistently supports Medicare requirements.
At its core, ExaCare transforms admissions by using AI to review hospital packets in minutes, automate document analysis, and support faster, better decision-making. It centralizes all referrals into one system, provides built-in analytics to optimize performance, and flags expensive medications and reimbursement risks before they impact the bottom line.
Ready to see how ExaCare can help your facility win more referrals and strengthen compliance?
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