US · guidance
CMS SOM App. A, Tag A-1164
§482.57(b)(4)- All respiratory care services orders must be documented in the
patient’s medical record in accordance with the requirements at §482.24.
Interpretive Guidelines §482.57(b)(4)
The patient’s medical record must contain documentation of all respiratory care services
ordered. The medical record entries must comply with regulations at 42 CFR 482.24.
Survey Procedures §482.57(b)(4)
Review a sample of patient medical records who received respiratory care services.
Determine whether the respiratory care services orders are legible, complete, dated,
timed, authenticated, and meet all other medical record requirements as specified at
§484.24.
History
Rev. 72, Issued: 11-18-11, Effective: 11-18-11, Implementation: 11-18-11
Provenance
- Source
- cms.gov
- Retrieved
- 2026-07-22
- Edition
- som-2026-07-22
- Content hash
19494a6e3e35105d69f0d4ed4f85623291707e66a40689c91277995493fe58a5
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