CMS SOM App. H, Tag V730

patient’s record, including whether the patient has executed an advance directive. These

records must be maintained in a manner such that each member of the interdisciplinary

team has access to current information regarding the patient’s condition and prescribed

treatment.

Interpretive Guidance § 494.170(b)(2)

“Centralized” means that the patient’s health information is maintained in a common location,

such as in a “chart” or electronic record system. At the time of publication of these regulations

(April 15, 2008, 73 FR 20369), many facilities maintained a combination of hard copy and

electronic records. If part or all of the record is maintained electronically, each member of the

IDT must be familiar with and able to access those areas of the patient record they would need

to use to stay current with the patient’s plan of care. The system in place must allow the

members of the IDT to promptly access the most current information about the patient and their

treatment.

Page 279 of 420

Dialysis treatment records (i.e. “flow sheets”) are the primary means of documenting the daily

care of hemodialysis patients. These records should contain complete information about the

treatment, such as pre- and post-treatment assessments, vital signs, vascular access in use, pre

and post treatment weights, machine parameters and safety checks (e.g. alarm tests, dialysate

pH and conductivity, dialysis prescription delivered (i.e. dialyzer, dialysate components, blood

and dialysate flow rates, length of treatment), medications given, any clinical events that

occurred during the treatment, and, any actions taken and responses to those actions.