[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

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

[CITE: 42CFR482.24]



[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 C_Basic Hospital Functions

 

Sec.  482.24  Condition of participation: Medical record services.



    The hospital must have a medical record service that has 

administrative responsibility for medical records. A



[[Page 503]]



medical record must be maintained for every individual evaluated or 

treated in the hospital.

    (a) Standard: Organization and staffing. The organization of the 

medical record service must be appropriate to the scope and complexity 

of the services performed. The hospital must employ adequate personnel 

to ensure prompt completion, filing, and retrieval of records.

    (b) Standard: Form and retention of record. The hospital must 

maintain a medical record for each inpatient and outpatient. Medical 

records must be accurately written, promptly completed, properly filed 

and retained, and accessible. The hospital must use a system of author 

identification and record maintenance that ensures the integrity of the 

authentification and protects the security of all record entries.

    (1) Medical records must be retained in their original or legally 

reproduced form for a period of at least 5 years.

    (2) The hospital must have a system of coding and indexing medical 

records. The system must allow for timely retrieval by diagnosis and 

procedure, in order to support medical care evaluation studies.

    (3) The hospital must have a procedure for ensuring the 

confidentiality of patient records. In-formation from or copies of 

records may be released only to authorized individuals, and the hospital 

must ensure that unauthorized individuals cannot gain access to or alter 

patient records. Original medical records must be released by the 

hospital only in accordance with Federal or State laws, court orders, or 

subpoenas.

    (c) Standard: Content of record. The medical record must contain 

information to justify admission and continued hospitalization, support 

the diagnosis, and describe the patient's progress and response to 

medications and services.

    (1) All entries must be legible and complete, and must be 

authenticated and dated promptly by the person (identified by name and 

discipline) who is responsible for ordering, providing, or evaluating 

the service furnished.

    (i) The author of each entry must be identifed and must authenticate 

his or her entry.

    (ii) Authentication may include signatures, written initials or 

computer entry.

    (2) All records must document the following, as appropriate:

    (i) Evidence of a physical examination, including a health history, 

performed no more than 7 days prior to admission or within 48 hours 

after admission.

    (ii) Admitting diagnosis.

    (iii) Results of all consultative evaluations of the patient and 

appropriate findings by clinical and other staff involved in the care of 

the patient.

    (iv) Documentation of complications, hospital acquired infections, 

and unfavorable reactions to drugs and anesthesia.

    (v) Properly executed informed consent forms for procedures and 

treatments specified by the medical staff, or by Federal or State law if 

applicable, to require written patient consent.

    (vi) All practitioners' orders, nursing notes, reports of treatment, 

medication records, radiology, and laboratory reports, and vital signs 

and other information necessary to monitor the patient's condition.

    (vii) Discharge summary with outcome of hospitalization, disposition 

of case, and provisions for follow-up care.

    (viii) Final diagnosis with completion of medical records within 30 

days following discharge.