[Code of Federal Regulations]
[Title 42, Volume 3]
[Revised as of October 1, 2002]
From the U.S. Government Printing Office via GPO Access
[CITE: 42CFR486.161]

[Page 613]
 
                         TITLE 42--PUBLIC HEALTH
 
  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 
                 HEALTH AND HUMAN SERVICES--(Continued)
 
PART 486--CONDITIONS FOR COVERAGE OF SPECIALIZED SERVICES FURNISHED BY SUPPLIERS--Table of Contents
 
Subpart D--Conditions for Coverage: Outpatient Physical Therapy Services 
        Furnished by Physical Therapists in Independent Practice
 
Sec. 486.161  Condition for coverage: Clinical records.

    The physical therapist in independent practice maintains clinical 
records on all patients in accordance with accepted professional 
standards and practices. The clinical records are completely and 
accurately documented, readily accessible, and systematically organized 
to facilitate retrieving and compiling information.
    (a) Standard: Protection of clinical record information. Clinical-
record information is recognized as confidential and is safeguarded 
against loss, destruction, or unauthorized use. Written procedures 
govern use and removal of records and include conditions for release of 
information. A patient's written consent is required for release of 
information not authorized by law.
    (b) Standard: Content. The clinical record contains sufficient 
information to identify the patient clearly, to justify the 
diagnosis(es) and treatment, and to document the results accurately. All 
clinical records contain the following general categories of data:
    (1) Documented evidence of the assessment of the needs of the 
patient, of an appropriate plan of care, and of the care and services 
provided,
    (2) Identification data and consent forms,
    (3) Medical history,
    (4) Report of physical examination(s), if any,
    (5) Observations and progress notes,
    (6) Reports of treatments and clinical findings, and
    (7) Discharge summary including final diagnosis(es) and prognosis.
    (c) Standard: Completion of records and centralization of reports. 
Current clinical records and those of discharged patients are completed 
promptly. All clinical information pertaining to a patient is 
centralized in the patient's clinical record.
    (d) Standard: Retention and preservation. Clinical records are 
retained for a period of time not less than:
    (1) That determined by the respective State statute or the statute 
of limitations in the State, or
    (2) In the absence of a State statute: (i) 5 years after the date of 
discharge or, (ii) in the case of a minor, 3 years after the patient 
becomes of age under State law, or 5 years after the date of discharge, 
whichever is longer.
    (e) Standard: Indexes. Clinical records are indexed at least 
according to name of patient to facilitate acquisition of statistical 
clinical information and retrieval of records for administrative action.

[41 FR 20865, May 21, 1976, unless otherwise noted. Redesignated at 42 
FR 52826, Sept. 30, 1977. Redesignated and amended at 60 FR 2326, 2329, 
Jan. 9, 1995]