US · guidance
CMS SOM App. A, Tag A-1624
§482.61(a)(3) The reasons for admission must be clearly documented as stated by
the patient and/or others significantly involved.
Interpretive Guidelines §482.61(a)(3)
The medical record must provide clear documentation of what caused the patient to come
to the hospital. The medical record must include the statements and reason(s) for
admission, given in the patient’s own words and/or given as a statement by a family
member, patient’s care provider, and/or other individual with knowledge of the patient’s
condition. The identity of the individual providing the statement or information must be
documented. The patient’s response to the admission should also be documented in the
medical record.
Survey Procedures §482.61(a)(3)
• Review the sample of patient records and verify that each medical record contains
the reason(s) for admission as stated by the patient and/or others significantly
involved.
o If the patient is unable to speak or verbalize the reason(s) for the
admission, does the documentation include statements from family
members, caregivers, or others who are significantly involved in the care
of the patient?
• Review the medical records for the patient’s response to the admission.
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
852ad0f682c3cd40388c8857a8582c5d2db27e5661347cc2e8e8cd1a9b355546
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