CMS SOM App. H, Tag V729

information. (1) Current medical records and those of discharged patients must be

completed promptly.

Interpretive Guidance § 494.170(b)(1):

“Completed promptly” for current (active) patient records means that each clinical event is

recorded as soon as possible after its occurrence, care interventions are recorded when

provided, and other pertinent patient health information (e.g. assessments, plans of care,

progress notes, medication administration, labs, radiology reports, medical orders) is recorded

in a timeframe that provides other IDT members with an up-to-date picture of the status of the

patient at all times (see also V730).

Facility policy must identify timeframes for the completion of medical records (e.g. signing of

verbal orders, completion of discharged patients’ records). The medical record system must have

a method for identification of the author, date and time of each entry. The author’s identification

may be by written signature, initials, computer key, or other code. If initials or computer codes

are used as signatures, there must be a means to identify the author of the entry. Rubber stamp

signatures are not permitted, as there are no means to identify the author with such a method.