US · guidance
CMS SOM App. L, Tag Q-0263
§416.52(a) Standard: Admission and Pre-surgical Assessment
(4) The patient's medical history and physical examination (if any) must be
placed in the patient's medical record prior to the surgical procedure.
Interpretive Guidelines: §416.52(a)(4)
The H&P, if one was required, must be placed in the patient’s medical record prior to the
pre-surgical assessment required under §416.52(a)(2), since that assessment should
consider the findings of the H&P before examining the patient prior to surgery. Both the
H&P, if any, and the pre-surgical assessment must be placed in the patient’s medical
record before the surgery.
Survey Procedures: §416.52(a)(4)
In the sample of medical records selected for review, verify that, for each patient
requiring an H&P per ASC policy, the record contains both the H&P and pre-surgical
assessment. Focus in particular on open records of patients scheduled for surgery during
the on-site survey, to determine whether these documents are in the patients’ records
before the start of their surgical procedures.
History
Rev. 206; Issued: 06-17-22; Effective: 06-17-22; Implementation: 06-17-22
Provenance
- Source
- cms.gov
- Retrieved
- 2026-07-22
- Edition
- som-2026-07-22
- Content hash
d72d3bd7c93666ba471cc388f53b0e9a519bfb83fbecd4a997365201f5ce64d8
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