What are the Centers for Medicare and Medicaid Services (CMS) documentation requirements for hospital beds?

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Last updated: February 25, 2025View editorial policy

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From the Guidelines

For hospital bed CMS documentation, healthcare providers must provide a complete description of the facility type and the number of beds, as per the CMS requirements 1. When documenting hospital beds, it is essential to include the facility type and the number of beds to ensure compliance with CMS regulations. This information is crucial for reimbursement and patient care purposes.

  • The facility description should include the type of facility, such as a hospital or outpatient facility.
  • The number of beds or patients should be clearly stated, as this information is used to determine reimbursement and resource allocation.
  • According to the study published in Clinical Microbiology Reviews 1, a complete description of the facility is necessary for accurate documentation.
  • The CMS requirements emphasize the importance of detailed documentation to support medical necessity and ensure proper reimbursement.
  • Healthcare providers should prioritize accurate and comprehensive documentation to avoid reimbursement issues and ensure high-quality patient care.
  • Daily updates to the patient's clinical course, response to treatment, and continued need for hospitalization are also essential for compliance with CMS requirements, as they demonstrate the medical necessity for hospital-level care 1.

From the Research

Centers for Medicare and Medicaid Services (CMS) Documentation Requirements

There are no specific studies provided that directly address the CMS documentation requirements for hospital beds.

General Documentation Requirements in Healthcare Settings

  • Accurate and complete medical record documentation is essential in any healthcare setting 2
  • Electronic health record (EHR) documentation is required for many reasons, including ensuring continuity of care 3
  • The quality of documentation can vary between electronic and paper medical records, with electronic medical records (EMRs) showing improvement in some areas 4
  • Electronic nursing documentation interventions can promote or improve patient safety and quality care in acute hospital settings 5

Documentation Practices and Efficiency

  • Bedside nurses' opinions on the efficiency of documentation practices can vary depending on the location of documentation 6
  • Clinicians spend significant time documenting patient care information in EHRs, with most time spent reviewing and documenting information 3
  • Organizations should provide ongoing education and awareness training for hospital clinical staff on available forms and best practices for effective and efficient documentation 3

References

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Research

Improving the quality of medical record documentation.

Journal for healthcare quality : official publication of the National Association for Healthcare Quality, 1992

Research

Use of electronic health record documentation by healthcare workers in an acute care hospital system.

Journal of healthcare management / American College of Healthcare Executives, 2014

Research

Comparison of the quality of documentation between electronic and paper medical records in orthopaedic trauma patients.

Australian health review : a publication of the Australian Hospital Association, 2022

Research

Bedside Nurse Documentation Practices: At the Patient Bedside or Not?

Computers, informatics, nursing : CIN, 2024

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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