US · guidance
CMS SOM App. W, Tag C-1106
§485.638(a)(3) A designated member of the professional staff is responsible for
maintaining the records and for ensuring that they are completely and accurately
documented, readily accessible, and systematically organized.
Interpretive Guidelines §485.638(a)(3)
The CAH must have one unified medical record service with a department head that has
been appointed by the governing body (or responsible individual). The director of
medical records must have responsibility for all medical records to include both inpatient
and outpatient records.
Survey Procedures §485.638(a)(3)
• Verify that the CAH employs adequate medical record personnel.
• Review the organizational structure and policy statements and interview the
person responsible for the service to ascertain that the medical records service is
structured appropriately to meet the needs of the CAH and the patients.
History
Rev. 200, Issued: 02-21-20; Effective: 02-21-20, Implementation: 02-21-20
Provenance
- Source
- cms.gov
- Retrieved
- 2026-07-22
- Edition
- som-2026-07-22
- Content hash
0ef7d21f88f240b894a0b2eada501cc95d8647d163e2b6ba5c6e39767573800d
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