CMS SOM App. K, Tag I-559

The facility must maintain clinical records on all patients in accordance with accepted

professional standards and practice. The clinical records must be completely, promptly,

systematically organized to facilitate retrieval and compilation of information.

A - General

The clinical record serves as a basis for documentation of care rendered to the patient and

communication between all personnel furnishing services. Determine whether the content of

the clinical record presents a total, or at a minimum, an adequate picture of the care being

given.

B - Major Sources of Information

• Active and closed clinical records; and

• Policies regarding protection and retention of clinical records.

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I-560, I-561, I-562, I-563, I-564, I-565, I-566, I-567

(Rev. 16, Issued: 01-10-06; Effective/Implementation Date: 11-21-05)

§485.60(a) Standard: Content

Each clinical record must contain sufficient information to identify the patient clearly and

to justify the diagnosis and treatment. Entries in the clinical record must be made as

frequently as is necessary to insure effective treatment, and must be signed by personnel

providing services. All entries made by assistant level personnel must be countersigned

by the corresponding professional. Documentation on each patient must be consolidated

into one clinical record that must contain:

(1) The initial assessment and subsequent reassessments of the patient’s needs;

(2) Current plan of treatment;

(3) Identification data and consent or authorization forms;

(4) Pertinent medical history, past and present;

(5) A report of pertinent physical examinations if any;

(6) Progress notes or other documentation that reflect patient reaction to

treatment, tests, or injury, or the need to change the established plan of

treatment; and

(7) Upon discharge, a discharge summary including patient status relative to goal

achievement, prognosis, and future treatment considerations.

All medical records must be maintained according to accepted professional standards of

practice. The medical records must be readily available to staff and surveyors.

Examine a substantial number of both active and closed clinical records and ascertain that the

required material is included. If any of the material required in this standard (§485.60(a) is

absent from the clinical records, review additional records to determine the prevalence of

such omissions. Record the number of records reviewed and the number and types of

deficiencies observed. In determining the number of records to be reviewed, be guided by

the size of the CORF's patient caseload. The larger the caseload, the larger the review

sample should be.

Each patient's record should contain a summary of each patient’s case review conference,

where appropriate, and indicate the purpose and recommendation resulting from the

conference. All reports generated as a result of any meetings concerning patient care issues

should be dated, signed and made a part of the record.

Ascertain that periodic progress notes are entered in the clinical records at intervals

commensurate with the type and frequency of treatment. These notes are to address the

progress of the patient in attaining stated plan of treatment goals. Some facilities may require

a brief entry in the clinical record each day the patient receives a treatment while other

facilities may require routine progress reports at longer intervals. Ascertain the time interval

between progress reports. Determine whether the time interval is impeding coordination and

communication in patient care activities. Regardless of the frequency of progress notes, the

notes should record the patient's status in relation to the stated treatment goals.

A discharge summary should include the date and reason for discharge, a brief summary of

the patient's current status and, where applicable, details regarding referral of the patient to

another level of care.

All information appearing in the clinical record must be dated, appropriately signed and

promptly incorporated in the record. Regulations require that entries written by therapy

assistants be countersigned even though some state practice acts may not require this. All

entries in the clinical record must be legible.

A physician must certify that CORF services are required because the individual needs

skilled rehabilitation services. The treatment plan must include a diagnosis and must address

rehabilitation goals associated with that particular diagnosis. Throughout the course of

rehabilitation treatment, the medical records must indicate the ongoing services provided by

a physical therapist, social worker or psychologist.

Verify the medical records contain signed and dated certifications and re-certifications.