CMS SOM App. A, Tag A-0449

The medical record must contain information to justify admission and continued

hospitalization, support the diagnosis, and describe the patient’s progress and response to

medications and services.

Interpretive Guidelines §482.24(c)

The medical record must contain information such as notes, documentation, records, reports,

recordings, test results, assessments etc. to:

• Justify admission;

• Justify continued hospitalization;

• Support the diagnosis;

• Describe the patient’s progress;

• Describe the patient’s response to medications; and

• Describe the patient’s response to services such as interventions, care, treatments, etc.

The medical record must contain complete information/documentation regarding evaluations,

interventions, care provided, services, care plans, discharge plans, and the patient’s response to

those activities.

Patient medical record information, such as, laboratory reports, test results, consults,

assessments, radiology reports, dictated notes, etc. must be promptly filed in the patient’s

medical record in order to be available to the physician and other care providers to use in making

assessments of the patient’s condition, to justify continued hospitalization, to support the

diagnosis, to describe the patient’s progress, and to describe the patient’s response to

medications, interventions, and services, in planning the patient’s care, and in making decisions

on the provision of care to the patient.