CMS SOM App. A, Tag A-1634

onset of illness and the circumstances leading to admission;

Interpretive Guidelines §482.61(b)(4)

For those patients that are admitted to the hospital as well as those being treated in the

outpatient setting, the practitioner completing the psychiatric evaluation must note the

onset of the patient’s illness and all relevant circumstances that lead to the present

admission or outpatient visit. The onset of illness and precipitating circumstances must

be clearly documented in the medical record as a component of the psychiatric

evaluation. The identified problem should be related to the patient’s need for hospital

admission and treatment, or related to the patient’s need for outpatient treatment in the

case of the outpatient setting. The psychiatric evaluation includes a history of present

illness, including onset, precipitating factors and reason for the current admission, signs

and symptoms, course of the illness and treatment(s), and the results of any treatment(s)

received.

Survey Procedures §482.61(b)(4)

• Review the sample of patient records and verify each contains information

regarding the onset of the patient’s illness and the precipitating circumstances

that lead to the current admission or outpatient visit.

• Review the sample of medical records to verify that identified problems are

documented and are indicated as related to the patient’s need for admission and

treatment or outpatient treatment.