CMS SOM App. A, Tag A-1620

Psychiatric Hospitals

The medical records maintained by a psychiatric hospital must permit

determination of the degree and intensity of the treatment provided to individuals

who are furnished services in the institution.

Interpretive Guidelines §482.61

All psychiatric hospitals must maintain written medical records. Those medical records

must be written and maintained in a manner that will allow surveyors to evaluate the

degree and intensity of treatment provided to individuals who are furnished services in

the hospital. The degree and intensity of treatment is determined by the number and type

of the therapeutic engagements, and the duration of treatments over a period of time.

The psychiatric hospital ensures that all medical records accurately and completely

document the need for admission, all orders, test results, evaluations, care plans,

treatment plans, treatments, treatment goals, interventions, care provided and the

patient’s responses to those treatments, interventions and care. The structure and

content of the individual patient’s record is expected to be a complete and accurate

representation of the patient’s actual experience while receiving care in the psychiatric

hospital.

In order for surveyors to evaluate the degree and intensity of treatment provided to each

patient, all entries in the medical records should be:

• Accurately written. The psychiatric hospital must ensure that all medical records

accurately and completely document all orders, test results, evaluations, care plans,

treatments, interventions, care provided and the patient’s response to those

treatments, interventions and care.

• Complete. A medical record is considered complete if it contains sufficient

information to identify the patient; support the diagnosis/condition; justify the care,

treatment, and services; document the course and results of care, treatment, and

services; and promote continuity of care among providers.

Survey Procedures §482.61

• Review a sample of patient records and verify that the degree of severity of mental

illness is documented in the medical records.

• Verify that the intensity of the treatment is documented in the medical records.

• Verify that records are accurate and complete.

• Verify that the patient’s response to treatments and interventions is documented

in the patient’s medical record.

• Determine whether all medical record entries are legible. Are they clearly

written in such a way that they are not likely to be misread or misinterpreted?