CMS SOM App. E, Tag I-181

A sample of active and closed clinical records is reviewed quarterly by the

appropriate health professionals to ensure that established policies are followed in

providing services.

Interpretive Guidelines §485.729(a)

A – General

The organization randomly selects a sample of clinical records from active and closed

files. The sample size should reflect each service offered by the organization. In

instances where a patient is receiving both physical therapy and speech pathology

services, the record may be included in the sample of each service rendered.

The clinical record review committee is composed of health professionals representing

those services provided directly and, if applicable, under arrangement, by the

organization. It is not necessary that those committee members be employees of the

organization.

Surveyors will review minutes or reports of the organization’s clinical record review

committee, and determine if the agency reviewed open and closed records that reflected

the services provided.

B – Major Sources of Information

• Minutes of meetings on clinical record review;

• The actual sample size and the types of clinical records selected (open and closed

records; reflect various services the organization provides);

• Organization policies and procedures regarding clinical record review, and sample

selection size; and

• Organizational chart.