US · guidance
CMS SOM App. A, Tag A-1630
§482.61(b) Standard: Psychiatric Evaluation
Each patient must receive a
psychiatric evaluation that must--
Interpretive Guidelines §482.61(b)
The psychiatric evaluation is done for the purpose of determining the patient’s diagnosis
and treatment. Therefore, it must contain the necessary information to justify the
diagnosis and planned treatment.
Survey Procedures §482.61(b)
• Review the hospital policies and procedures for completing the psychiatric
evaluations. If utilized, verify non-physician practitioners are privileged to
complete part or all of the psychiatric evaluation.
• Review the sample of patient records and verify that a psychiatric evaluation has
been completed and documented in the medical record for the patients.
• If there is a change in psychiatric diagnosis or if a new diagnosis is added, verify
that the change in diagnosis is supported by documentation of the patient’s
condition or the current symptoms the patient exhibits. The rationale for changing
the diagnosis must be documented.
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
0dd0bb71693a701554630d8b2fc58368a52364b302e7d1d6c0307e721fdce00f
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