[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: 42CFR485.60]



[Page 598]

 

                         TITLE 42--PUBLIC HEALTH

 

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

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 485_CONDITIONS OF PARTICIPATION: SPECIALIZED PROVIDERS--Table 

of Contents

 

    Subpart B_Conditions of Participation: Comprehensive Outpatient 

                        Rehabilitation Facilities

 

Sec. 485.60  Condition of participation: Clinical records.



    The facility must maintain clinical records on all patients in 

accordance with accepted professional standards and practice. The 

clinical records must be completely, promptly, and accurately 

documented, readily accessible, and systematically organized to 

facilitate retrieval and compilation of information.

    (a) Standard: Content. Each clinical record must contain sufficient 

information to identify the patient clearly and to justify the diagnosis 

and treatment. Entries in the clinical record must be made as frequently 

as is necessary to insure effective treatment and must be signed by 

personnel providing services. All entries made by assistant level 

personnel must be countersigned by the corresponding professional. 

Documentation on each patient must be consolidated into one clinical 

record that must contain--

    (1) The initial assessment and subsequent reassessments of the 

patient's needs;

    (2) Current plan of treatment;

    (3) Identification data and consent or authorization forms;

    (4) Pertinent medical history, past and present;

    (5) A report of pertinent physical examinations if any;

    (6) Progress notes or other documentation that reflect patient 

reaction to treatment, tests, or injury, or the need to change the 

established plan of treatment; and

    (7) Upon discharge, a discharge summary including patient status 

relative to goal achievement, prognosis, and future treatment 

considerations.

    (b) Standard: Protection of clinical record information. The 

facility must safeguard clinical record information against loss, 

destruction, or unauthorized use. The facility must have procedures that 

govern the use and removal of records and the conditions for release of 

information. The facility must obtain the patient's written consent 

before releasing information not required to be released by law.

    (c) Standard: Retention and preservation. The facility must retain 

clinical record information for 5 years after patient discharge and must 

make provision for the maintenance of such records in the event that it 

is no longer able to treat patients.