CMS SOM App. H, Tag V726

on all patients, including home patients who elect to receive dialysis supplies and

equipment from a supplier that is not a provider of ESRD services and all other home

dialysis patients whose care is under the supervision of the facility.

Interpretive Guidance § 494.170

Page 276 of 420

Medical records includes printed or electronic information such as, but not limited to, patient

consents, histories and physicals, medication reports, radiology reports, laboratory reports,

dialysis treatment orders, patient assessments, patient plans of care, treatment records, and

progress notes regarding the condition and care of the patient. Each patient’s medical record,

whether hard copy, electronic, or a combination of both, should include complete and pertinent

information about the condition of the patient, assessments by the IDT , updated plans of care,

all interventions and treatments prescribed and delivered, and details of any events occurring

with the patient during the course of treatment. No matter what format, the record of care must

be readily accessible to every authorized member of the healthcare team so that care can be

coordinated to best meet the needs of the patient.

The facility must create and maintain a complete and accurate record of care for every patient

that is unique for that patient. Each patient’s medical record should clearly portray the patient,

the care provided by the facility personnel, and the outcomes of that care.

V731 in this Condition and V599 under the Condition for care at home also address the records

of home patients.