Nick-Maximillien/medgate-compiler-data huggingface dataset:
Guideline text:
(Rev. 37, Issued:  10-17-08; Effective/Implementation Date:  10-17-08)

§482.24(b)(1) - Medical records must be retained in their original or legally reproduced form for a period of at least 5 years.

## Interpretive Guidelines §482.24(b)(1)

Medical records are retained in their original or legally reproduced form in hard copy, microfilm, computer memory, or other electronic storage media.  The hospital must be able to promptly retrieve the complete medical record of every individual evaluated or treated in any part or location of the hospital within the last 5 years.

In accordance with Federal and State law and regulations, certain medical records may have retention requirements that exceed 5 years (for example:  FDA, OSHA, EPA).

## Survey Procedures §482.24(b)(1)

- Determine that records are retained for at least 5 years, or more if required by State or local laws.
- Select a sample of patients, both inpatient and outpatient who were patients of the hospital between the previous 48-60 months.  Request their medical record.  Is it promptly retrieved?  Is it complete?  Is it in original or in a legally reproduced form?

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance", "integrity"], "logic_config": {"required_artifact": "medical records", "retention_details": {"form_types": ["original", "legally reproduced"], "min_years": 5, "retrievability": "promptly retrieve complete record"}}, "rule_type": "existence", "scope_tags": ["clinical", "facility", "legal"]}
Guideline text:
Conflict of interest disclosures are available online. [Ref: 299]

Structured rule (JSON):
{"intent_tags": [], "logic_config": {}, "rule_type": "unsupported", "scope_tags": [], "summary": "Non-executable narrative text"}
Guideline text:
Limit EKG interpretation to 8 units per session.

Structured rule (JSON):
{"intent_tags": ["safety"], "logic_config": {"event_type": "ekg", "max_count": 8}, "rule_type": "count_sanity", "scope_tags": ["clinical"]}
Guideline text:
It is recommended to adapt the choice and dosage of antithrombotic agent, as well as of secondary prevention medications, to renal function, co-medications, comorbidities, frailty, cognitive function, and specific contraindications. 363 , 712

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"forbidden_treatment": "Antithrombotic agent or secondary prevention medications (standard choice/dosage)", "trigger_condition": "renal function impairment, co-medication interactions, comorbidities, frailty, cognitive impairment, or specific contraindications"}, "rule_type": "contra", "scope_tags": ["clinical"]}
Guideline text:
Limit consultation to 4 units per session.

Structured rule (JSON):
{"intent_tags": ["safety"], "logic_config": {"event_type": "consultation", "max_count": 4}, "rule_type": "count_sanity", "scope_tags": ["clinical"]}
Guideline text:
PCI with stent deployment in the IRA during the index procedure is recommended for patients undergoing PPCI.

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"required_artifact": "PCI with stent deployment in the IRA during the index procedure", "trigger_assertion": "patient is undergoing PPCI"}, "rule_type": "conditional_existence", "scope_tags": ["clinical"]}
Guideline text:
It is recommended that ambulance teams are trained and equipped to identify ECG patterns suggestive of acute coronary occlusion and to administer initial therapy, including defibrillation, and fibrinolysis when applicable.

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"required_artifact": "ambulance teams trained and equipped to identify ECG patterns suggestive of acute coronary occlusion and to administer initial therapy, including defibrillation and fibrinolysis"}, "rule_type": "existence", "scope_tags": ["clinical"]}
Guideline text:
Routine oxygen is not recommended in patients without hypoxaemia (SaO2 >90%). 148 , 172

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"min_value": 90, "operator": ">", "target_vital": "SaO2"}, "rule_type": "threshold", "scope_tags": ["clinical"]}
Guideline text:
(Rev. 37, Issued:  10-17-08; Effective/Implementation Date:  10-17-08)

The hospital must have and implement written protocols that:

## Interpretive Guidelines §482.45(a)

The hospital must have written policies and procedures to address its organ procurement responsibilities.

Structured rule (JSON):
{"intent_tags": ["compliance", "quality", "safety"], "logic_config": {"required_artifact": "written policies and procedures for organ procurement responsibilities"}, "rule_type": "existence", "scope_tags": ["facility", "legal"]}
Guideline text:
(Rev. 37, Issued:  10-17-08; Effective/Implementation Date:  10-17-08)

[When restraint or seclusion is used, there must be documentation in the patient's medical record of the following:]

§482.13(e)(16)(ii) - A description of the patient's behavior and the intervention used.

## Interpretive Guidelines §482.13(e)(16)(ii)

Documentation that must be included in the patient's medical record when the patient is restrained or secluded includes a description of the patient's behavior and the intervention used.  The patient's behavior should be documented in descriptive terms to evaluate the appropriateness of the interventions used.  The documentation should include a detailed description of the patient's physical and mental status assessments, and of any environmental factors (e.g., physical, milieu, activities, etc.) that may have contributed to the situation at the time of the intervention.

## Survey Procedures §482.13(e)(16(ii)

- Does the patient's medical record include a clear description of the patient's behavior that warranted the use of restraint or seclusion?
- Was the intervention employed appropriate for the identified behavior?
- What was the patient's clinical response to the intervention(s)?

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance", "integrity"], "logic_config": {"required_artifact": "documentation in the patient's medical record of the patient's behavior and the intervention used", "trigger_assertion": "restraint or seclusion is used"}, "rule_type": "conditional_existence", "scope_tags": ["clinical", "legal"]}
Guideline text:
The level of evidence for this section is based on expert consensus. [Ref: 973]

Structured rule (JSON):
{"intent_tags": [], "logic_config": {}, "rule_type": "unsupported", "scope_tags": [], "summary": "Non-executable narrative text"}
Guideline text:
Discontinuation of parenteral anticoagulation should be considered immediately after an invasive procedure.

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"anchor": "invasive procedure", "max_delay_minutes": 0, "target": "discontinuation of parenteral anticoagulation"}, "rule_type": "temporal", "scope_tags": ["clinical"]}
Guideline text:
Aspirin is not recommended in cancer patients with a platelet count <10 000/μL. 715

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"forbidden_treatment": "Aspirin", "patient_population": "cancer patients", "trigger_condition": {"lab_test": "Platelet Count", "operator": "<", "type": "lab_threshold", "unit": "/\u03bcL", "value": 10000}}, "rule_type": "contra", "scope_tags": ["clinical"]}
Guideline text:
Complete revascularization is recommended either during the index PCI procedure or within 45 days. 508 – 511 , 531

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"anchor": "index PCI procedure", "max_delay_days": 45, "target": "complete revascularization"}, "rule_type": "temporal", "scope_tags": ["clinical"]}
Guideline text:
(Rev. 200, Issued: 02-21-20; Effective: 02-21-20, Implementation: 02-21-20)

## §482.42(c)(1) Standard:  Leadership responsibilities

(1) The governing body must ensure all of the following:

(i)  Systems are in place and operational for the tracking of all infection surveillance, prevention, and control, and antibiotic use activities, in order to demonstrate the implementation, success, and sustainability of such activities.

## Interpretive Guidelines §482.42(c)(1)(i)

Guidance is pending and will be updated in future release.

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance", "integrity"], "logic_config": {"required_artifact": "systems for tracking infection surveillance, prevention, control, and antibiotic use activities"}, "rule_type": "existence", "scope_tags": ["facility", "clinical", "legal"]}
Guideline text:
In patients with ACS and severe/refractory CS, short-term mechanical circulatory support may be considered. 402

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"required_artifact": "short-term mechanical circulatory support", "trigger_assertion": "patient has Acute Coronary Syndrome (ACS) and severe/refractory Cardiogenic Shock (CS)"}, "rule_type": "conditional_existence", "scope_tags": ["clinical"]}
Guideline text:
Pacing is not recommended if high-degree AV block resolves after revascularization or spontaneously. 620 – 622

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"forbidden_treatment": "Pacing", "trigger_condition": "high-degree AV block resolves after revascularization or spontaneously"}, "rule_type": "contra", "scope_tags": ["clinical"]}
Guideline text:
Conflict of interest disclosures are available online. [Ref: 489]

Structured rule (JSON):
{"intent_tags": [], "logic_config": {}, "rule_type": "unsupported", "scope_tags": [], "summary": "Non-executable narrative text"}
Guideline text:
(Rev. 72, Issued: 11-18-11, Effective: 11-18-11, Implementation: 11-18-11)

§482.56(b)(1) All rehabilitation services orders must be documented in the patient's medical record in accordance with the requirements at §482.24.

Interpretive Guidelines §482.56(b)(1)

The patient's medical record must contain documentation of all rehabilitation services ordered.  The medical record entries must comply with regulations at §482.24.

## Survey Procedures §482.56(b)(1)

Review a sample of patient medical records who received rehabilitation services. Determine whether the rehabilitation service orders are legible, complete, dated, timed, authenticated, and meet all other medical record requirements specified at §482.24.

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance", "integrity"], "logic_config": {"required_artifact": "documentation of rehabilitation services orders in patient's medical record", "trigger_assertion": "rehabilitation services ordered"}, "rule_type": "conditional_existence", "scope_tags": ["clinical", "legal"]}
Guideline text:
Patients with NSTE-ACS For patients with NSTE-ACS in whom early invasive angiography (i.e. within 24 h) is not anticipated, fondaparinux is recommended.

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"required_artifact": "fondaparinux administration", "trigger_assertion": "NSTE-ACS diagnosis and early invasive angiography not anticipated within 24 hours"}, "rule_type": "conditional_existence", "scope_tags": ["clinical"]}
Guideline text:
(Rev. 37, Issued:  10-17-08; Effective/Implementation Date:  10-17-08)

## §482.56(a) Standard:  Organization and Staffing

The organization of the service must be appropriate to the scope of the services offered.

## Interpretive Guidelines §482.56(a)

The hospital must provide the appropriate equipment and types and numbers of qualified personnel necessary to furnish the rehabilitation services offered by the hospital in accordance with acceptable standards of practice.

The scope of rehabilitation services offered by the hospital should be defined in written policies and procedures, and approved by the Medical staff.

Each service, whether provided through a single discipline department or within a multidiscipline department, must function with established lines of authority and responsibility to ensure the health and safety of patients.  There must be an adequate number of qualified staff available when needed to evaluate each patient, initiate the plan of treatment, and supervise supportive personnel when they furnish rehabilitation services. The number of qualified staff is based on the type of patients treated and the frequency, duration, and complexity of the treatment required.

## Survey Procedures §482.56(a)

- Review the hospital's policies and procedures to verify that the scope of rehabilitation services offered is defined in writing.
- If services are provided under an arrangement, review policies and contracts.
- For each service, determine that adequate types and numbers of qualified staff are available to ensure safe and efficient provision of treatment.
- Review medical records to verify that a qualified professional evaluates the patient and initiates each treatment episode.
- Review a sample of personnel files to verify current licensure, certifications and ongoing training, consistent with applicable State laws.

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance"], "logic_config": {"required_artifact": "appropriate organization and staffing for rehabilitation services"}, "rule_type": "existence", "scope_tags": ["facility", "clinical"]}
Guideline text:
In patients at HBR, c dabigatran 110 mg b.i.d. should be considered in preference to dabigatran 150 mg b.i.d. for the duration of concomitant SAPT or DAPT, to mitigate bleeding risk. 305

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"forbidden_treatment": "dabigatran 150 mg b.i.d.", "reason": "to mitigate bleeding risk", "recommended_alternative_treatment": "dabigatran 110 mg b.i.d.", "trigger_condition": "patients at High Bleeding Risk (HBR) with concomitant SAPT or DAPT"}, "rule_type": "contra", "scope_tags": ["clinical"]}
Guideline text:
It is recommended that EMS transfer patients with suspected STEMI to a PCI-capable centre, bypassing non-PCI centres.

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"required_artifact": "transfer to a PCI-capable centre, bypassing non-PCI centres", "trigger_assertion": "suspected STEMI"}, "rule_type": "conditional_existence", "scope_tags": ["clinical"]}
Guideline text:
In HBR patients, aspirin or P2Y12 receptor inhibitor monotherapy after 1 month of DAPT may be considered. 276 , 313

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"required_artifact": "consideration of aspirin or P2Y12 receptor inhibitor monotherapy", "trigger_assertion": "patient is High Bleeding Risk (HBR) AND has completed at least 1 month of DAPT"}, "rule_type": "conditional_existence", "scope_tags": ["clinical"]}
Guideline text:
(Rev. 37, Issued:  10-17-08; Effective/Implementation Date:  10-17-08)

[The governing body must:]

§482.12(a)(7) Ensure that under no circumstances is the accordance of staff membership or professional privileges in the hospital dependent solely upon certification, fellowship or membership in a specialty body or society.

## Interpretive Guidelines §482.12(a)(7)

In making a judgment on medical staff membership, a hospital may not rely solely on the fact that a MD/DO is, or is not, board-certified.  This does not mean that a hospital is prohibited from requiring board certification when considering a MD/DO for medical staff membership, but only that such certification must not be the only factor that the hospital considers.  In addition to matters of board certification, a hospital must also consider other criteria such as training, character, competence and judgment.  After analysis of all of the criteria, if all criteria are met except for board certification, the hospital has the discretion to decide not to select that individual to the medical staff.

## Survey Procedures §482.12(a)(7)

Verify that written criteria for appointment to the medical staff and granting of medical staff privileges are not dependent solely upon certification, fellowship, or membership in a specialty body or society.

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance"], "logic_config": {"required_artifact": "evidence that the decision was based on multiple criteria (e.g., training, character, competence, judgment) and not solely on certification, fellowship, or membership in a specialty body or society", "trigger_assertion": "decision on staff membership or professional privileges is being made"}, "rule_type": "conditional_existence", "scope_tags": ["facility", "legal"]}
Guideline text:
(Rev. 200, Issued: 02-21-20; Effective: 02-21-20, Implementation: 02-21-20)

## §482.42(a) Standard: Infection prevention and control program organization and policies.  The hospital must demonstrate that:

(1) An individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control  program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership;

## Interpretive Guidelines §482.42(a)(1)

Guidance is pending and will be updated in future release.

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance"], "logic_config": {"required_artifact": "qualified infection preventionist(s)/infection control professional(s) appointed by governing body based on recommendations of medical staff and nursing leadership"}, "rule_type": "existence", "scope_tags": ["facility", "legal"]}
Guideline text:
(Rev. 37, Issued:  10-17-08; Effective/Implementation Date:  10-17-08)

§482.13(e) (1) Definitions. (i) A restraint is-

(A)  Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or

## Interpretive Guidelines §482.13(e)(1)(i)(A)

This restraint definition applies to all uses of restraint in all hospital care settings.  Under this definition, commonly used hospital devices and other practices could meet the definition of a restraint, such as:

- Tucking a patient's sheets in so tightly that the patient cannot move;
- Use of a 'net bed' or an 'enclosed bed' that prevents the patient from freely exiting the bed. EXCEPTION :  Placement of a toddler in an "enclosed" or "domed" crib;
- Use of "Freedom" splints that immobilize a patient's limb;
- Using side rails to prevent a patient from voluntarily getting out of bed; or
- Geri chairs or recliners, only if the patient cannot easily remove the restraint appliance and get out of the chair on his or her own.

NOTE : Generally, if a patient can easily remove a device, the device would not be considered a restraint.  In this context, 'easily remove' means that the manual method, device, material, or equipment can be removed intentionally by the patient in the same manner as it was applied by the staff (e.g., side rails are put down, not climbed over; buckles are intentionally unbuckled; ties or knots are intentionally untied; etc.) considering the patient's physical condition and ability to accomplish objective (e.g., transfer to a chair, get to the bathroom in time).

- Determine whether the hospital's policy and procedures employ a definition or description of what constitutes a restraint that is consistent with the regulation.
- While touring hospital units look for restraints in use.  Where a restraint is in use, check the medical record for appropriate documentation.
- Interview hospital staff to determine whether they know the definition of a restraint.

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance"], "logic_config": {"required_artifact": "appropriate documentation in medical record", "trigger_assertion": "restraint is in use"}, "rule_type": "conditional_existence", "scope_tags": ["clinical", "facility", "legal"]}
Guideline text:
Aspirin is not recommended in cancer patients with a platelet count <10 000/μL.

Structured rule (JSON):
{"intent_tags": ["safety"], "logic_config": {"forbidden_treatment": "Aspirin", "patient_population": "cancer patients", "trigger_condition": {"lab_name": "platelet count", "operator": "<", "type": "lab_value_threshold", "unit": "/\u03bcL", "value": 10000}}, "rule_type": "contra", "scope_tags": ["clinical"]}
Guideline text:
Patient discharge information should be provided in both written and verbal formats prior to discharge. Adequate preparation and education for patient discharge using the teach back technique and/or motivational interviewing, giving information in chunks, and checking for understanding should be considered. 885 , 896 , 911

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"required_artifact": "discharge information provided in both written and verbal formats", "trigger_assertion": "patient discharge occurs"}, "rule_type": "conditional_existence", "scope_tags": ["clinical"]}
Guideline text:
Emergency angiography and PCI of the IRA, if indicated are recommended in patients with new-onset or persistent heart failure/shock after fibrinolysis. 185 , 225

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"required_artifact": "Emergency angiography and PCI of the IRA", "trigger_assertion": "new-onset or persistent heart failure/shock after fibrinolysis"}, "rule_type": "conditional_existence", "scope_tags": ["clinical"]}
Guideline text:
A proton pump inhibitor in combination with DAPT is recommended in patients at high risk of gastrointestinal bleeding. 287 , 288

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"required_artifact": "A proton pump inhibitor in combination with DAPT", "trigger_assertion": "patients at high risk of gastrointestinal bleeding"}, "rule_type": "conditional_existence", "scope_tags": ["clinical"]}
Guideline text:
The committee met in 2024 to review the guidelines. [Ref: 868]

Structured rule (JSON):
{"intent_tags": [], "logic_config": {}, "rule_type": "unsupported", "scope_tags": [], "summary": "Non-executable narrative text"}
Guideline text:
Routine PCI of an occluded IRA is not recommended in STEMI patients presenting >48 h after symptom onset and without persistent symptoms. 189 , 192 , 193

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"forbidden_treatment": "Routine PCI of an occluded IRA", "trigger_condition": "STEMI patients presenting >48 h after symptom onset and without persistent symptoms"}, "rule_type": "contra", "scope_tags": ["clinical"]}
Guideline text:
If patients presenting with ACS stop DAPT to undergo CABG, it is recommended they resume DAPT after surgery for at least 12 months.

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"required_artifact": "DAPT resumed for at least 12 months after CABG surgery", "trigger_assertion": "patient with ACS stops DAPT for CABG"}, "rule_type": "conditional_existence", "scope_tags": ["clinical"]}
Guideline text:
Limit physical therapy unit to 4 units per session.

Structured rule (JSON):
{"intent_tags": ["safety"], "logic_config": {"event_type": "physical", "max_count": 4}, "rule_type": "count_sanity", "scope_tags": ["clinical"]}
Guideline text:
It is recommended to measure cardiac troponins with high-sensitivity assays immediately after presentation and to obtain the results within 60 min of blood sampling. 15 , 25 – 27

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"anchor": "blood sampling", "max_delay_minutes": 60, "target": "troponin results obtained"}, "rule_type": "temporal", "scope_tags": ["clinical"]}
Guideline text:
If timely PPCI (<120 min) cannot be performed in patients with a working diagnosis of STEMI, fibrinolytic therapy is recommended within 12 h of symptom onset in patients without

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"required_artifact": "fibrinolytic therapy within 12 hours of symptom onset", "trigger_assertion": "timely PPCI (<120 min) cannot be performed in patients with a working diagnosis of STEMI"}, "rule_type": "conditional_existence", "scope_tags": ["clinical"]}