US · guidance
CMS SOM App. A, Tag A-0463
[All records must document the following, as appropriate:]
§482.24(c)(4)(ii) - Admitting diagnosis.
Interpretive Guidelines §482.24(c)(4)(ii)
All inpatient medical records must contain the admitting diagnosis.
Survey Procedures §482.24(c)(4)(ii)
Verify in a sample of medical records that the patient’s admitting diagnosis is documented in
each medical record.
History
Rev. 95, Issued: 12-12-13, Effective: 06-07-13, Implementation: 06-07-13
Provenance
- Source
- cms.gov
- Retrieved
- 2026-07-22
- Edition
- som-2026-07-22
- Content hash
8757f49938b3bfa50dacb16a24dad6c26acd3aea7e9825f6f050f16025fdbd56
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