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US · guidance

CMS Pub. 100-02, ch. 2, § 30

Medical Records Requirements

activein force · 2026-08-25 – presentas-observed

The medical records maintained by an IPF must permit determination of the degree and

intensity of the treatment provided to individuals who are furnished services in the

institution.

In addition, consistent with the hospital conditions of participation, all medical records,

including progress notes and treatment plan, should be legible and complete, and should

be promptly signed and dated by the person (identified by name and discipline) who is

responsible for ordering, providing or evaluating the service furnished.

History

(Rev. 253, Issued: 12- 14-18, Effective: 01-16-19, Implementation: 01- 16-19)

Provenance

Source
cms.gov
Retrieved
2026-08-25
Edition
iom-2026-08-25
Content hash
164658e5dd78ef0aa8396f019a6dd7ba32248cbd6010fa499b9d7c9913848a83
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