US · guidance
CMS SOM App. J, Tag W111
§483.410(c)(1) that documents the client's health care, active treatment, social information,
and protection of the client's rights.
Guidance §483.410(c)(1)
The structure and content of a client’s record must be an accurate, functional representation of
the actual experience of the client in the facility.
The record should contain an accurate account of all information relevant to the client’s health
care, active treatment, social information and protection of the client’s rights, such as
communications, correspondence, program plans (to include both in-house and outside service
programs), progress summaries, activity plans and activity participation, incidents, consent
forms and all medical information.
If the records are maintained electronically, the facility staff should be able to access various
parts of the record without difficulty. If they are unable to access components of the record
upon request, then this may indicate a lack of training by the facility.
History
Rev. 135, Issued: 02-27-15, Effective: 04-27-15, Implementation: 04-27-15
Provenance
- Source
- cms.gov
- Retrieved
- 2026-07-22
- Edition
- som-2026-07-22
- Content hash
f4531766cfef8809b36aaf7b24320a563a951b35583e909e5126e27f4921023d
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