[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: 42CFR485.638]



[Page 625-626]

 

                         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 

 

 Subpart F_Conditions of Participation: Critical Access Hospitals (CAHs)

 

Sec.  485.638  Conditions of participation: Clinical records.



    (a) Standard: Records system--(1) The CAH maintains a clinical 

records system in accordance with written policies and procedures.

    (2) The records are legible, complete, accurately documented, 

readily accessible, and systematically organized.

    (3) A designated member of the professional staff is responsible for 

maintaining the records and for ensuring that they are completely and 

accurately documented, readily accessible, and systematically organized.

    (4) For each patient receiving health care services, the CAH 

maintains a record that includes, as applicable--

    (i) Identification and social data, evidence of properly executed 

informed consent forms, pertinent medical history, assessment of the 

health status and health care needs of the patient, and a brief summary 

of the episode, disposition, and instructions to the patient;

    (ii) Reports of physical examinations, diagnostic and laboratory 

test results, including clinical laboratory services, and consultative 

findings;

    (iii) All orders of doctors of medicine or osteopathy or other 

practitioners, reports of treatments and medications, nursing notes and 

documentation of complications, and other pertinent information 

necessary to monitor the patient's progress, such as temperature 

graphics, progress notes describing the patient's response to treatment; 

and



[[Page 626]]



    (iv) Dated signatures of the doctor of medicine or osteopathy or 

other health care professional.

    (b) Standard: Protection of record information--(1) The CAH 

maintains the confidentiality of record information and provides 

safeguards against loss, destruction, or unauthorized use.

    (2) Written policies and procedures govern the use and removal of 

records from the CAH and the conditions for the release of information.

    (3) The patient's written consent is required for release of 

information not required by law.

    (c) Standard: Retention of records. The records are retained for at 

least 6 years from date of last entry, and longer if required by State 

statute, or if the records may be needed in any pending proceeding.



[58 FR 30671, May 26, 1993, as amended at 62 FR 46037, Aug. 29, 1997]