CMS SOM App. A, Tag A-1650

way to assure that all active therapeutic efforts are included.

Interpretive Guidelines §482.61(c)(2)

Active treatment is an essential requirement for psychiatric care. Active treatment is a

clinical process involving ongoing assessment, diagnosis, intervention, evaluation of care

and treatment, and planning for discharge and aftercare, under the direction of a

psychiatrist.

All aspects of treatment and therapeutic efforts, to which the hospital has committed

itself, based upon the patient’s assessment, evaluation and plan of care, must be

documented in the medical record. It is the hospital’s responsibility to provide those

treatment modalities with sufficient frequency and intensity to assure that the patient

achieves his/her optimal level of functioning.

The medical record must contain evidence that the patient’s rights are being addressed

and protected during therapeutic efforts. Refer to §482.13(a), Standard: Notice of

Rights, Tags A0116 through A0217.

Clarification of the types of notes found in the medical record.

Treatment notes are recordings in the medical record that indicate provision of, and a

patient’s response to, a specific modality. This modality may be drug therapy, individual,

family, marital, or group therapy, art therapy, recreational therapy, and any specialized

therapy ordered by the physician or other practitioners acting within their scope of

practice and hospital policy to write orders in the medical record.

A combined treatment and progress note may be written.

Progress notes are recordings in the medical record that are written by persons directly

responsible for the care and active treatment of the patient. Progress notes give a

chronological picture of how the patient is progressing toward the accomplishment of the

individual goals in the treatment plan.

Survey Procedures §482.61(c)(2)

• Review a sample of medical records and verify staff members are recording their

interventions and therapeutic efforts in such a way that the interventions and

therapeutic efforts are included.

• Verify documentation of treatment progress is written as an objective description

of observed or monitored behaviors of the patient in response to the treatment

modalities, including medication.

• Interview the patient, family member or others significantly involved with the

patient, and the staff to determine if a patient is actively involved in assigned

treatment.

• If the patient is not actively involved in the assigned treatment, review the

documentation to determine if the reason has been documented. Refer to

§482.61(c)(1)(v), Tag A1645.

• Review the progress notes to determine if progress or lack thereof has been

documented.

• Verify that all treatment team members document their observations and

interventions so that the information is available and accessible to the entire

team.