CMS SOM App. A, Tag A-0431

The hospital must have a medical record service that has administrative responsibility for

medical records. A medical record must be maintained for every individual evaluated or

treated in the hospital.

Interpretive Guidelines §482.24

The term “hospital” includes all locations of the hospital.

The hospital must have one unified medical record service that has administrative responsibility

for all medical records, both inpatient and out patient records. The hospital must create and

maintain a medical record for every individual, both inpatient and out patient evaluated or treated

in the hospital.

The term “medical records” includes at least written documents, computerized electronic

information, radiology film and scans, laboratory reports and pathology slides, videos, audio

recordings, and other forms of information regarding the condition of a patient.

Survey Procedures §482.24

• Review the organizational structure and policy statements and interview the person

responsible for the medical records service to ascertain that the service is structured

appropriately to meet the needs of the hospital and the patients.

• Review a sample of active and closed medical records for completeness and accuracy in

accordance with Federal and State laws and regulations and hospital policy. The sample

should be 10 percent of the average daily census and be no less than 30 records.

Additionally, select a sample of outpatient records in order to determine compliance in

outpatient departments, services, and locations.