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US · guidance

CMS SOM App. U, Tag R112

(2) Maintain the records and information in an accurate and timely manner

activein force · 2026-07-22 – presentas-observed

Interpretive Guidelines: §403.730(d)(2)

The RNHCI must have complete, comprehensive and accurate patient records. Patient

records should be maintained continuously during the patient’s stay at the RNCHI and

the organization must ensure that records are completed in a timely manner and

accessible to the patient and/or patient’s representative in a timely manner.

Survey Procedures:

• Review a sample of active and closed patient records for completeness and

accuracy in accordance with Federal and State laws and regulations and the

RNHCI policy.

• Does the record include the necessary and most current information about the

patient?

• Interview staff and ask them to describe the process for maintaining and updating

a patient’s record.

History

Rev. 239; Issued: 04-24-26; Effective: 04-24-26; Implementation: 04-24-26

Provenance

Source
cms.gov
Retrieved
2026-07-22
Edition
som-2026-07-22
Content hash
3bdfc0e67722ca7dc459a43af0c6eddea97a31a10161d2dad32e5c481e7b17bd
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