CMS SOM App. A, Tag A-1632

a medical history;

Interpretive Guidelines §482.61(b)(2)

In addition to the psychiatric diagnosis and history, the psychiatric evaluation must

include the patient’s non-psychiatric medical history, including physiological problems,

physical and intellectual disabilities, and the recommended treatment. The purpose of a

medical history is to determine whether there is anything in the patient's overall

condition that would affect the planned course of the patient's treatment, such as a

medication allergy, or a new or existing co-morbid condition that requires additional

interventions to reduce risk to the patient.

The medical history is a collection of medical information that physicians or other

practitioners obtained from assessing a patient or by asking specific questions, either of

the patient or of other individuals who know the patient and can give suitable information

about the patient’s health condition, present illness or history of past illness. The

medical history will guide the treatment team in formulating the patient’s medical

diagnosis and providing the medical treatment the patient needs while receiving

psychiatric care. See Medical Staff CoP at §482.22(c)(5)(i) for more comprehensive

details for H&P requirements.

Survey Procedures §482.61(b)(2)

• Review the sample of patient records and verify that the psychiatric evaluation

includes a medical history which would include such notations as medication

allergies, co-morbid conditions, other intellectual challenges, etc.