[Code of Federal Regulations]

[Title 42, Volume 3]

[Revised as of October 1, 2005]

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

[CITE: 42CFR482.61]



[Page 502-503]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 482_CONDITIONS OF PARTICIPATION FOR HOSPITALS--Table of Contents

 

             Subpart E_Requirements for Specialty Hospitals

 

Sec. 482.61  Condition of participation: Special medical record 

requirements for psychiatric hospitals.



    The medical records maintained by a psychiatric hospital must permit 

determination of the degree and intensity of the treatment provided to 

individuals who are furnished services in the institution.

    (a) Standard: Development of assessment/diagnostic data. Medical 

records must stress the psychiatric components of the record, including 

history of findings and treatment provided for the psychiatric condition 

for which the patient is hospitalized.

    (1) The identification data must include the patient's legal status.

    (2) A provisional or admitting diagnosis must be made on every 

patient at the time of admission, and must include the diagnoses of 

intercurrent diseases as well as the psychiatric diagnoses.

    (3) The reasons for admission must be clearly documented as stated 

by the patient and/or others significantly involved.

    (4) The social service records, including reports of interviews with 

patients, family members, and others, must provide an assessment of home 

plans and family attitudes, and community resource contacts as well as a 

social history.

    (5) When indicated, a complete neurological examination must be 

recorded at the time of the admission physical examination.

    (b) Standard: Psychiatric evaluation. Each patient must receive a 

psychiatric evaluation that must--

    (1) Be completed within 60 hours of admission;

    (2) Include a medical history;

    (3) Contain a record of mental status;

    (4) Note the onset of illness and the circumstances leading to 

admission;

    (5) Describe attitudes and behavior;

    (6) Estimate intellectual functioning, memory functioning, and 

orientation; and

    (7) Include an inventory of the patient's assets in descriptive, not 

interpretative, fashion.

    (c) Standard: Treatment plan. (1) Each patient must have an 

individual comprehensive treatment plan that must be based on an 

inventory of the patient's strengths and disabilities. The written plan 

must include--

    (i) A substantiated diagnosis;

    (ii) Short-term and long-range goals;

    (iii) The specific treatment modalities utilized;



[[Page 503]]



    (iv) The responsibilities of each member of the treatment team; and

    (v) Adequate documentation to justify the diagnosis and the 

treatment and rehabilitation activities carried out.

    (2) The treatment received by the patient must be documented in such 

a way to assure that all active therapeutic efforts are included.

    (d) Standard: Recording progress. Progress notes must be recorded by 

the doctor of medicine or osteopathy responsible for the care of the 

patient as specified in Sec. 482.12(c), nurse, social worker and, when 

appropriate, others significantly involved in active treatment 

modalities. The frequency of progress notes is determined by the 

condition of the patient but must be recorded at least weekly for the 

first 2 months and at least once a month thereafter and must contain 

recommendations for revisions in the treatment plan as indicated as well 

as precise assessment of the patient's progress in accordance with the 

original or revised treatment plan.

    (e) Standard: Discharge planning and discharge summary. The record 

of each patient who has been discharged must have a discharge summary 

that includes a recapitulation of the patient's hospitalization and 

recommendations from appropriate services concerning follow-up or 

aftercare as well as a brief summary of the patient's condition on 

discharge.



[51 FR 22042, June 17, 1986; 51 FR 27848, Aug. 4, 1986]