CMS Pub. 100-02, ch. 2, § 30.1

In accordance with 42 CFR 412.27(c) and 42 CFR 482.61(a), 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. According to

the Interpretative Guidelines for 482.61(a)(1) given in the State Operations Manual

(SOM; see IOM 100-07, Appendix AA), legal status is defined in the State statutes and

dictates the circumstances under which the patient was admitted and/or is being treated - i.e.,

voluntary, involuntary, committed by court, evaluation and recertification are in accordance

with State requirements.

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

time of admission, and must include the diagnoses of comorbid conditions 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.