CMS Pub. 100-11, ch. 12, § 10.2

The medical record must contain the following:

• Appropriate identifying information;

• Documentation of all services furnished, including the following:

o A summary of emergency care and other inpatient or long-term care

services;

o Services furnished by employees of the PACE center;

o Services furnished by contractors and their reports;

• Interdisciplinary assessments, reassessments, plans of care, treatment, and

progress notes that include the participant’s response to treatment;

• Laboratory, radiological and other test reports;

• Medication records;

• Hospital discharge summaries, if applicable;

• Reports of contact with informal support (e.g., caregiver, legal guardian, or

next of kin);

• Enrollment Agreement;

• Physician orders;

• Discharge summary and disenrollment justification, if applicable;

• Advance directives, if applicable;

• A signed release permitting disclosure of personal information.

The actual incident report is not a required element of the participant medical record.

However, a narrative description of the care rendered during and subsequent to the

incident is required. This narrative description should be documented in the progress

notes of the IDT specialist(s) rendering care. If the incident results in a significant change

in health status, the changes in the problem, interventions, measurable outcomes,

timelines for monitoring and evaluation, and responsible person(s) performing the

intervention should be updated in the individual’s care plan.

[42 CFR § 460.210(b); 71 FR 71326 through 71327 (Dec. 8, 2006)]