CMS SOM App. A, Tag A-1626

recorded at the time of the admission physical examination.

Interpretive Guidelines §482.61(a)(5)

The Hospital CoPs, Tag A-0358 Hospital standard §482.22(c)(5)(i), requires that a

medical history and physical be completed and documented for each patient, no more

than 30 days before or 24 hours after admission or registration, but prior to surgery or a

procedure requiring anesthesia services. The medical history and physical examination

must be completed and documented by a physician (as defined in section 1861(r) of the

Act), an oral and maxillofacial surgeon, or other qualified licensed individual in

accordance with State law and hospital policy. Any concerns related to the medical

history and physical examination requirements should be cited under Tag A-0358. The

examining practitioner makes a determination, in accordance with State law and hospital

policy, as to whether a neurological examination is warranted. If the findings of the

medical history and physical examination indicate the need for a neurological

examination, it must be completed at the same time the admission physical examination is

being conducted and must be documented in the medical record.

Survey Procedures §482.61(a)(5)

• Review the sample of patient records and verify that, when the history and

physical examination indicates, a neurological examination was completed and

documented at the time the admission history and physical examination was

completed.

• If no neurological examination is present in the medical record, is there

documentation from the practitioner who completed the history and physical

examination that states a neurological examination was not indicated?

• Verify that neurological function screening/examination was done (when

indicated) and recorded at the time of the admission physical examination, and

that a complete, comprehensive neurological exam was ordered, completed and

recorded in the medical record in a timely manner.