US · guidance
CMS SOM App. A, Tag A-1622
§482.61(a)(1) The identification data must include the patient’s legal status
Interpretive Guidelines §482.61(a)(1)
The patient’s legal status when admitted to a psychiatric hospital may be classified as
voluntary, involuntary or committed by court. The legal status must be documented in
the patient’s medical record. If the admission and treatment is involuntary or committed
by court, the medical record must contain documentation required by state law or from
the court.
Survey Procedure §482.61(a)(1):
• Review a sample of medical records to verify that the patient’s legal status is
accurately documented.
• Review a sample of medical records to verify that documentation required by
state law or court order is present. If the inpatient admission or outpatient
treatment is involuntary, verify documentation that the psychiatric hospital has
submitted a court hearing notification.
• If evaluation and recertification is required by the State, determine that the legal
documentation supporting the patient’s legal status is present. Changes in the
patient’s legal status are recorded with the date and time of the change, and the
person determining the change in status is present and is properly identified in
the record.
History
Rev. 238; Issued: 03-20-26; Effective: 09-05-25; Implantation: 09-05-25
Provenance
- Source
- cms.gov
- Retrieved
- 2026-07-22
- Edition
- som-2026-07-22
- Content hash
8201703c0530adae5dffa299fcee21c323509152a4d68ffeb61a34cfae57ba61
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