US · guidance
CMS SOM App. A, Tag A-0465
[All records must document the following, as appropriate:]
§482.24(c)(4)(iv) - Documentation of complications, hospital acquired infections, and
unfavorable reactions to drugs and anesthesia.
Interpretive Guidelines §482.24(c)(4)(iv)
All patient medical records, both inpatient and outpatient, must document:
• Complication;
• Hospital-acquired infections;
• Unfavorable reactions to drugs; and
• Unfavorable reactions to anesthesia.
Survey Procedures §482.24(c)(4)(iv)
Through observations, interviews, and reviews of hospital reports and documentation, determine
if patient complications, hospital-acquired infections, unfavorable reactions to drugs/anesthesia
have been documented in the applicable 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
5e4795393c83885a90dc43b8f0b0740d80a4a0423992b96b69b221c6c41400e7
The link goes to the issuing authority’s own document — the one we read to produce this record. Where a source publishes whole titles rather than sections, your browser may need a moment to jump to the provision.
Unofficial copy of government-published law, reproduced from official sources with full provenance. Not an official publication; verify against official sources before relying on it in a filing. Records in the 'guidance' corpus, and only that corpus, are sub-regulatory (interpretive guidelines, survey procedures) and are not binding law. Validity bounds follow each jurisdiction's declared temporalBasis.