US · guidance
CMS SOM App. A, Tag A-1645
§482.61(c)(1)(v) [The written plan must include—] Adequate documentation to justify
the diagnosis and the treatment and rehabilitation activities carried out.
Interpretive Guidelines §482.61(c)(1)(v)
All psychiatric hospitals must provide documentation with sufficient frequency to justify
the patient’s diagnosis, and the treatment and rehabilitative activities that are carried
out. The content of the notes must indicate the reason(s) for the treatment provided, the
rehabilitative activities provided, and the patient’s response to the treatment and
rehabilitative activity. Additionally, the progress and treatment notes should reflect the
goals of the individualized treatment plan. The numbers, types, frequency, and content of
progress and treatment notes completed by appropriate qualified personnel may be
evidence of adequate documentation.
Survey Procedures §482.61(c)(1)(v)
• Review the sample of medical records to determine if there is adequate
documentation in progress and treatment notes to justify the patient’s diagnosis
and the treatment and rehabilitative activities that were carried out; Refer to
§482.61(d), Tag A1660, for minimum frequency requirements.
• Verify the appropriate qualified personnel completed the progress and treatment
notes.
• Verify that the patient’s participation and responses to the treatment and
rehabilitative activities are 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
663cca89ba75b8986cc6219cbab9fa2de3a5cefa767dc7f0bc15bd49c53ab5b6
The link goes to the issuing authority’s own document — the one we read to produce this record. Where a source publishes whole titles rather than sections, your browser may need a moment to jump to the provision.
Unofficial copy of government-published law, reproduced from official sources with full provenance. Not an official publication; verify against official sources before relying on it in a filing. Records in the 'guidance' corpus, and only that corpus, are sub-regulatory (interpretive guidelines, survey procedures) and are not binding law. Validity bounds follow each jurisdiction's declared temporalBasis.