CMS SOM App. W, Tag C-1116

practitioners, reports of treatments and medications, nursing notes and

documentation of complications, and other pertinent information necessary to

monitor the patient's progress, such as temperature graphics, progress notes

describing the patient's response to treatment; and

Interpretive Guidelines §485.638(a)(4)(iii)

The requirement means that the stated information is necessary to monitor the patient’s

condition and that this and other necessary information must be in the patient’s medical

record. In order for necessary information to be used it must be promptly filed in the

medical record so that health care staff involved in the patient’s care can access/retrieve

this information in order to monitor the patient’s condition and provide appropriate care.

The medical record must contain:

• All practitioner’s orders (properly authenticated);

• All nursing notes;

• All reports of treatment (including complications and CAH-acquired infections);

• All medication records (including unfavorable reactions to drugs);

• All radiology reports;

• All laboratory reports;

• All vital signs; and

• All other information necessary to monitor the patient’s condition.

All medical records must be promptly completed. Every medical record must be

complete with all documentation of orders, diagnosis, evaluations, treatments, test results,

consents, interventions, discharge summary, and care provided along with the patient’s

response to those treatments, interventions, and care.

Survey Procedures §485.638(a)(4)(iii)

• Verify that the patient records contain appropriate documentation of practitioners'

orders, interventions, findings, assessments, records, notes, reports and other

information necessary to monitor the patient's condition.

• Is necessary information included in patient records in a prompt manner so that

health care staff involved in the care of the patient have access to the information

necessary to monitor the patient’s condition?