US · guidance
CMS SOM App. M, Tag L685
§418.104(f) Standard: Retrieval of clinical records
The clinical record, whether hard copy or in electronic form, must be made readily
available on request by an appropriate authority.
Interpretive Guidelines §418.104(f)
An appropriate authority includes representatives from the SA or other authorized entity,
who visits the hospice for the purpose of determining in accordance with Section 1864(a)
of the Act whether the hospice is meeting all conditions of participation.
If the clinical record is maintained electronically, the hospice must provide all equipment
necessary to read the record in its entirety. The hospice must also produce a paper copy
of the record, if requested by the surveyor. In addition, ascertain how the hospice ensures
that the record is up-to-date including documentation of recent services/visits or
handwritten notes held by staff that were not included in the record when the paper copy
was produced.
History
Rev. 210; Issued:02-03-23; Effective:02-03-23; Implementation:02-03-23
Provenance
- Source
- cms.gov
- Retrieved
- 2026-07-22
- Edition
- som-2026-07-22
- Content hash
da52c9b3a47bf4a2e0fafa7119c49b5768d9a8633eb7c02d182872fb8e1ac6bf
The link goes to the issuing authority’s own document — the one we read to produce this record. Where a source publishes whole titles rather than sections, your browser may need a moment to jump to the provision.
Unofficial copy of government-published law, reproduced from official sources with full provenance. Not an official publication; verify against official sources before relying on it in a filing. Records in the 'guidance' corpus, and only that corpus, are sub-regulatory (interpretive guidelines, survey procedures) and are not binding law. Validity bounds follow each jurisdiction's declared temporalBasis.