CMS SOM App. A, Tag A-0432

The organization of the medical record service must be appropriate to the scope and

complexity of the services performed. The hospital must employ adequate personnel to

ensure prompt completion, filing, and retrieval of records.

Interpretive Guidelines §482.24(a)

The medical records service must be organized, equipped, and staffed in accordance with the

scope and complexity of the hospital’s services and in such a manner as to comply with the

requirements of this regulation and other Federal and State laws and regulations.

There must be an established medical record system that is organized and employs adequate

personnel to ensure prompt:

• Completion of medical records;

• Filing of medical records; and

• Retrieval of medical records.

The term “employs adequate personnel” includes:

• That medical record personnel are employees of the hospital;

• That the hospital employs an adequate number of medical record personnel, employs

adequate types of medical record personnel, and employs personnel who possess

adequate education, skills, qualifications and experience to ensure the hospital complies

with requirements of this regulation and other Federal and State laws and regulations.

Survey Procedures §482.24(a)

• Verify that there is an established system that addresses at least the following activities of

the medical records services:

o Timely processing of records;

o Coding/indexing of records;

o Retrieval of records;

o Compiling and retrieval of data of quality assurance activities.

• Verify that the system is reviewed and revised as needed.

• Interview staff, if needed, review written job descriptions and staffing schedules to

determine if staff is carrying out all designated responsibilities.

• Verify that the hospital employs adequate medical record personnel as previously

described.

• Are medical records promptly completed in accordance with State law and hospital

policy?

• Select a sample of past patients of the hospital (inpatient and/or outpatient). Request

those patients’ medical records. Can the hospital promptly retrieve those records?