US · guidance
CMS SOM App. A, Tag A-0464
[All records must document the following, as appropriate:]
§482.24(c)(4)(iii) - Results of all consultative evaluations of the patient and appropriate
findings by clinical and other staff involved in the care of the patient.
Interpretive Guidelines §482.24(c)(4)(iii)
All patient records, both inpatient and outpatient, must contain the results of all consultative
evaluations of the patient and appropriate findings by clinical and other staff involved in the care
of the patient. This information must be promptly filed in the patient’s medical record in order to
be available to the physician or other care providers to use in making assessments of the patient’s
condition, to justify treatment or continued hospitalization, to support or revise the patient’s
diagnosis, to support or revise the plan of care, to describe the patient’s progress and to describe
the patient’s response to medications, treatments, and services.
Survey Procedures §482.24(c)(4)(iii)
Review a sample of medical records of patients who have orders for consultative evaluations.
Are the results/reports and other clinical findings of those consultative evaluations included in
the patient’s 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
2f1b73cd1e71ac0fad176dd431fc6930bf8d5a652d3e4ac5486cbb5a514c39c2
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