CMS SOM App. A, Tag A-0438

The hospital must maintain a medical record for each inpatient and outpatient. Medical

records must be accurately written, promptly completed, properly filed and retained, and

accessible. The hospital must use a system of author identification and record maintenance

that ensures the integrity of the authentication and protects the security of all record

entries.

Interpretive Guidelines §482.24(b)

The hospital must maintain a medical record for each inpatient and outpatient evaluated or

treated in any part or location of the hospital.

All medical records must be accurately written. The hospital must ensure that all medical

records accurately and completely document all orders, test results, evaluations, care plans,

treatments, interventions, care provided and the patient’s response to those treatments,

interventions and care.

All medical records must be promptly completed. Every medical record must be complete with

all documentation of orders, diagnosis, evaluations, treatments, test results, care plans, discharge

plans, consents, interventions, discharge summary, and care provided along with the patient’s

response to those treatments, interventions, and care. The record must be completed promptly

after discharge in accordance with State law and hospital policy but no later than 30 days after

discharge.

The medical record must be properly filed and retained. The hospital must have a medical

record system that ensures the prompt retrieval of any medical record, of any patient evaluated or

treated at any location of the hospital within the past 5 years. [§482.24(b)(1) addresses the 5

year medical record retention requirement]

The medical record must be accessible. The hospital must have a medical record system that

allows the medical record of any patient, inpatient or outpatient, evaluated and/or treated at any

location of the hospital within the past 5 years to be accessible by appropriate staff, 24 hours a

day, 7 days a week, whenever that medical record may be needed.

Medical records must be properly stored in secure locations where they are protected from fire,

water damage and other threats.

Medical information such as consultations, orders, practitioner notes, x-ray interpretations, lab

test results, diagnostic test results, patient assessments and other patient information must be

accurately written, promptly completed and properly filed in the patients’ medical record, and

accessible to the physicians or other care providers when needed for use in making assessments

of the patient’s condition, decisions on the provision of care to the patient, and in planning the

patient’s care. This requirement applies to the medical records of current inpatients and

outpatients of the hospital.

The hospital must have a system of author identification and record maintenance that ensures the

integrity of the authentication and protects the security of all record entries. The medical record

system must correctly identify the author of every medical record entry and must protect the

security of all medical record entries. The medial record system must ensure that medical record

entries are not lost, stolen, destroyed, altered, or reproduced in an unauthorized manner.

Locations where medical records are stored or maintained must ensure the integrity, security and

protection of the records. These requirements apply to both manual and electronic medical

record systems.

Survey Procedures §482.24(b)

• Determine the location(s) where medical records are maintained.

• Verify that a medical record is maintained for each person treated or receiving care. The

hospital may have a separate record for both inpatients and outpatients. However, when

two different systems are used they must be appropriately cross referenced and

accessible.

• Verify that procedures ensure the integrity of authentication and protect the security of

patient records.

• Verify that medical records are stored and maintained in locations where the records are

secure, that protects them from damage, flood, fire, etc., and limits access to only

authorized individuals.

• Verify that records are accurate, completed promptly, easily retrieved and readily

accessible, as needed, in all locations where medical records are maintained.