Guideline text:
(Rev. 200, Issued: 02-21-20; Effective: 02-21-20, Implementation: 02-21-20)

## §482.24(c)(4) - All records must document the following, as appropriate:

(i)  Evidence of -(C)   An assessment of the patient (in lieu of the requirements of paragraphs (c)(4)(i)(A) and (B) of this section) completed and documented after registration, but prior to surgery or a procedure requiring anesthesia services, when the patient is receiving specific outpatient surgical or procedural services and when the medical staff has chosen to develop and maintain a policy that identifies, in accordance with the requirements at § 482.22(c)(5)(v), specific patients as not requiring a comprehensive medical history and physical examination, or any update to it, prior to specific outpatient surgical or procedural services.

## Interpretive Guidelines §482.23(c)(4)(i)(C)

Guidance is pending and will be updated in future release.

A-0463

(Rev. 95, Issued: 12-12-13, Effective: 06-07-13, Implementation: 06-07-13)

[All records must document the following, as appropriate:]

§482.24(c)(4)(ii) - Admitting diagnosis.

Interpretive Guidelines §482.24(c)(4)(ii)

All inpatient medical records must contain the admitting diagnosis.

## Survey Procedures §482.24(c)(4)(ii)

Verify in a sample of medical records that the patient's admitting diagnosis is documented in each medical record.

A-0464

(Rev. 95, Issued: 12-12-13, Effective: 06-07-13, Implementation: 06-07-13)

[All records must document the following, as appropriate:]

§482.24(c)(4)(iii) - Results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient.

## Interpretive Guidelines §482.24(c)(4)(iii)

All patient records, both inpatient and outpatient, must contain the results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient.  This information must be promptly filed in the patient's medical record in order to be available to the physician or other care providers to use in making assessments of the patient's condition, to justify treatment or continued hospitalization, to support or revise the patient's diagnosis, to support or revise the plan of care, to describe the patient's progress and to describe the patient's response to medications, treatments, and services.

## Survey Procedures §482.24(c)(4)(iii)

Review a sample of medical records of patients who have orders for consultative evaluations.  Are the results/reports and other clinical findings of those consultative evaluations included in the patient's medical record?

A-0465

(Rev. 95, Issued: 12-12-13, Effective: 06-07-13, Implementation: 06-07-13)

[All records must document the following, as appropriate:]

§482.24(c)(4)(iv) - Documentation of complications, hospital acquired infections, and

## unfavorable reactions to drugs and anesthesia.

## Interpretive Guidelines §482.24(c)(4)(iv)

All patient medical records, both inpatient and outpatient, must document:

- Complication;
- Hospital-acquired infections;
- Unfavorable reactions to drugs; and
- Unfavorable reactions to anesthesia.

## Survey Procedures §482.24(c)(4)(iv)

Through observations, interviews, and reviews of hospital reports and documentation, determine if patient complications, hospital-acquired infections, unfavorable reactions to drugs/anesthesia have been documented in the applicable patient's medical record.

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance"], "logic_config": {"required_artifact": "patient assessment", "temporal_constraint_end_event": "surgery or procedure requiring anesthesia services", "temporal_constraint_start_event": "registration", "temporal_constraint_type": "between", "trigger_assertion": "patient is receiving specific outpatient surgical or procedural services AND medical staff policy identifies specific patients as not requiring a comprehensive medical history and physical examination"}, "rule_type": "conditional_existence", "scope_tags": ["clinical", "facility"]}