US · guidance
CMS SOM App. A, Tag A-0469
[All records must document the following, as appropriate:]
§482.24(c)(4)(viii) - Final diagnosis with completion of medical records within 30 days
following discharge.
Interpretive Guidelines §482.24(c)(4)(viii)
All medical records must contain a final diagnosis. All medical records must be complete within
30 days of discharge or outpatient care.
Survey Procedures §482.24(c)(4)(viii)
Select a sample of patients who have been discharged for more than 30 days. Request their
medical records. Are those records complete? Does each record have the patient’s final
diagnosis?
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
2e83ce12a6de137ba994900975fe052d1bbe10511f08265a030a78d4c345cc69
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