[Code of Federal Regulations]

[Title 42, Volume 2]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR416.47]



[Page 815]

 

                         TITLE 42--PUBLIC HEALTH

 

                    CHAPTER IV--CENTERS FOR MEDICARE

                          & MEDICAID SERVICES,

                        DEPARTMENT OF HEALTH AND

                             HUMAN SERVICES

 

PART 416_AMBULATORY SURGICAL SERVICES--Table of Contents

 

               Subpart C_Specific Conditions for Coverage

 

Sec. 416.47  Condition for coverage--Medical records.



    The ASC must maintain complete, comprehensive, and accurate medical 

records to ensure adequate patient care.

    (a) Standard: Organization. The ASC must develop and maintain a 

system for the proper collection, storage, and use of patient records.

    (b) Standard: Form and content of record. The ASC must maintain a 

medical record for each patient. Every record must be accurate, legible, 

and promptly completed. Medical records must include at least the 

following:

    (1) Patient identification.

    (2) Significant medical history and results of physical examination.

    (3) Pre-operative diagnostic studies (entered before surgery), if 

performed.

    (4) Findings and techniques of the operation, including a 

pathologist's report on all tissues removed during surgery, except those 

exempted by the governing body.

    (5) Any allergies and abnormal drug reactions.

    (6) Entries related to anesthesia administration.

    (7) Documentation of properly executed informed patient consent.

    (8) Discharge diagnosis.



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