CMS SOM App. H, Tag V502

The patient’s comprehensive assessment must

include, but is not limited to, the following: (1) Evaluation of current health status and

medical condition, including co-morbid conditions.

Interpretive Guidance §494.80 (a)(1)

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ESRD patients may have many co-morbid conditions that impact their individual care needs. The

IDT evaluation of the patient’s current medical and co-morbid conditions includes information

from the patient’s medical history, physical exams, and, nursing histories.

Non-physician practitioners, i.e., advanced practice registered nurses or physician assistants,

functioning in lieu of physicians, may conduct medical portions of this evaluation, in accordance

with State law and facility policy.

The nursing assessment must be conducted by a registered nurse and include evidence of

assessing the patient's clinical needs.

Documentation of the etiology of the patient's kidney disease and a listing of any co-morbid

conditions should be in the medical record. While copies of histories and physicals (H&P) from

hospital admissions may be included, the assessment should address the patient's current

presentation and health status, including the patient’s medical condition related to their kidney

disease.