CMS SOM App. A, Tag A-0467

§482.24(c)(4)(vi) - All practitioners’ orders, nursing notes, reports of treatment, medication

records, radiology, and laboratory reports, and vital signs and other information necessary

to monitor the patient’s condition.

Interpretive Guidelines §482.24(c)(4)(vi)

The requirement means that the stated information is necessary to monitor the patient’s condition

and that this and other necessary information must be in the patient’s medical record. In order

for necessary information to be used it must be promptly filed in the medical record so that

health care staff involved in the patient’s care can access/retrieve this information in order to

monitor the patient’s condition and provide appropriate care.

The medical record must contain:

• All practitioner’s orders (properly authenticated);

• All nursing notes (including nursing care plans);

• All reports of treatment (including complications and hospital-acquired infections);

• All medication records (including unfavorable reactions to drugs);

• All radiology reports;

• All laboratory reports;

• All vital signs; and

• All other information necessary to monitor the patient’s condition.

Survey Procedures §482.24(c)(4)(vi)

• Verify that the patient records contain appropriate documentation of practitioners’ orders,

interventions, findings, assessments, records, notes, reports and other information

necessary to monitor the patient’s condition.

• Is this information included in patient records in a prompt manner so that health care staff

involved in the care of the patient have access to the information necessary to monitor the

patient’s condition?