Nick-Maximillien/medgate-compiler-data huggingface dataset:
Guideline text:
It is recommended to intensify lipid-lowering therapy during the index ACS hospitalization for patients who were on lipid-lowering therapy before admission.

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"required_artifact": "intensified lipid-lowering therapy", "trigger_assertion": "patient was on lipid-lowering therapy before admission and is in index ACS hospitalization"}, "rule_type": "conditional_existence", "scope_tags": ["clinical"]}
Guideline text:
The level of evidence for this section is based on expert consensus. [Ref: 498]

Structured rule (JSON):
{"intent_tags": [], "logic_config": {}, "rule_type": "unsupported", "scope_tags": [], "summary": "Non-executable narrative text"}
Guideline text:
During PCI, a UFH bolus is recommended in any of the following circumstances: • if the patient is on a NOAC • if the INR is <2.5 in VKA-treated patients.

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"required_artifact": "UFH bolus during PCI", "trigger_assertion": "patient is on a NOAC OR INR is <2.5 in VKA-treated patients"}, "rule_type": "conditional_existence", "scope_tags": ["clinical"]}
Guideline text:
(Rev. 200, Issued: 02-21-20; Effective: 02-21-20, Implementation: 02-21-20)

§482.43(c)(1) -The hospital must include the discharge planning a list of HHA's, SNF's, IRF's, or LTCH's that are available to the patient, that are participating in the Medicare program, and that serve the geographic area (as defined by the HHA) in which the patient resides, or in the case of a SNF, IRF, or LTCH, in the geographic area requested by the patient. HHAs must request to be listed by the hospital as available.

(i) The list must only be presented to patients for whom home health care post hospital extended care services, SNF, IRF, or LTCH services are indicated and appropriate as determined by the discharge planning evaluation. (ii) For patients enrolled in managed care organizations, the hospital must make the patient aware of the need to verify with their managed care organization which practitioners, providers or certified suppliers are in the network of the patient's managed care organization, it must share this with the

patient or the patient's representative.

(iii)  [The hospital must] document in the patient's medical record that the list was presented to the patient or to the patient's representative.….

## Interpretive Guidelines §482.43(c)(1)(i)-(iii)

Guidance is pending and will be updated in future release.

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance"], "logic_config": {"required_artifact": "documentation in medical record that list of available post-acute care providers was presented to patient or representative", "trigger_assertion": "discharge planning evaluation indicates patient requires post-acute care services (HHA, SNF, IRF, or LTCH)"}, "rule_type": "conditional_existence", "scope_tags": ["clinical", "facility", "legal"]}
Guideline text:
(Rev. 59, Issued: 05-21-10, Effective/Implementation: 05-21-10)

[The policies must ensure that the following are provided for each patient:]

§482.52(b)(2) - An intraoperative anesthesia record.

Interpretive Guidelines §482.52(b)(2)

There must be an intraoperative anesthesia record or report for each patient who receives general, regional or monitored anesthesia.  While current practice dictates that the patient receiving moderate sedation be monitored and evaluated before, during, and after the procedure by trained practitioners, an intraoperative anesthesia report is not required because, as explained above , moderate sedation is not 'anesthesia'.  Current standard of care stipulates that an intraoperative anesthesia record, at a minimum, includes:

- Name and hospital identification number of the patient;
- Name(s) of practitioner(s) who administered anesthesia, and as applicable, the name and profession of the supervising anesthesiologist or operating practitioner;
- Name, dosage, route and time of administration of drugs and anesthesia agents;
- Techniques(s) used and patient position(s), including the insertion/use of any intravascular or airway devices;
- Name and amounts of IV fluids, including blood or blood products if applicable;
- Timed-based documentation of vital signs as well as oxygenation and ventilation parameters; and
- Any complications, adverse reactions, or problems occurring during anesthesia, including time and description of symptoms, vital signs, treatments rendered, and patient's response to treatment.

## Survey Procedures §482.52(b)(2)

Review records to determine that each patient has an intraoperative anesthesia record that includes the elements described above.

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance", "integrity"], "logic_config": {"exclusion_criteria": "moderate sedation", "required_artifact": "intraoperative anesthesia record", "required_elements": ["Name and hospital identification number of the patient", "Name(s) of practitioner(s) who administered anesthesia, and as applicable, the name and profession of the supervising anesthesiologist or operating practitioner", "Name, dosage, route and time of administration of drugs and anesthesia agents", "Techniques(s) used and patient position(s), including the insertion/use of any intravascular or airway devices", "Name and amounts of IV fluids, including blood or blood products if applicable", "Timed-based documentation of vital signs as well as oxygenation and ventilation parameters", "Any complications, adverse reactions, or problems occurring during anesthesia, including time and description of symptoms, vital signs, treatments rendered, and patient's response to treatment"], "trigger_assertion": "patient receives general, regional or monitored anesthesia"}, "rule_type": "conditional_existence", "scope_tags": ["clinical", "legal"]}
Guideline text:
Cannot bill IV Infusion and IV Push on the same service date.

Structured rule (JSON):
{"intent_tags": ["compliance"], "logic_config": {"event_1": "IV Infusion", "event_2": "IV Push"}, "rule_type": "exclusive", "scope_tags": ["billing"]}
Guideline text:
In patients treated with streptokinase, an i.v. bolus of fondaparinux followed by an s.c. dose 24 h later should be considered. 260

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"anchor": "i.v. bolus of fondaparinux", "context_condition": "in patients treated with streptokinase", "max_delay_hours": 24, "min_delay_hours": 24, "target": "s.c. dose of fondaparinux"}, "rule_type": "temporal", "scope_tags": ["clinical"]}
Guideline text:
Limit EKG interpretation to 6 units per session.

Structured rule (JSON):
{"intent_tags": ["safety"], "logic_config": {"event_type": "ekg", "max_count": 6}, "rule_type": "count_sanity", "scope_tags": ["clinical"]}
Guideline text:
Shift handovers must be recorded in chronological sequence.

Structured rule (JSON):
{"intent_tags": ["integrity"], "logic_config": {"event_type": "shift_handovers"}, "rule_type": "monotonic", "scope_tags": ["clinical"]}
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)(v) - The patient's response to the intervention(s) used, including the rationale for continued use of the intervention.

## Survey Procedures §482.13(e)(16)(v):

- Does the patient's medical record include descriptions of the impact of the intervention on the patient behavior that resulted in the use of restraint or seclusion?
- Does the patient's medical record include a detailed assessment of the patient's response to the intervention and a well-reasoned plan for the continued use of restraint or seclusion?

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance"], "logic_config": {"required_artifact": "documentation of the patient's response to the intervention(s) used, including the rationale for continued use of the intervention", "trigger_assertion": "restraint or seclusion is used"}, "rule_type": "conditional_existence", "scope_tags": ["clinical", "legal"]}
Guideline text:
(Rev. 37, Issued:  10-17-08; Effective/Implementation Date:  10-17-08)

[The hospital must require appropriate staff to have education, training, and

## demonstrated knowledge based on the specific needs of the patient population in at least the following:]

§482.13(f)(2)(v) -  Clinical identification of specific behavioral changes that indicate that restraint or seclusion is no longer necessary.

## Interpretive Guidelines §482.13(f)(2)(v)

The use of restraint or seclusion must be ended at the earliest possible time regardless of the length of time identified in the order.  Staff must be trained and demonstrate competency in their ability to identify specific patient behavioral changes that may indicate that restraint or seclusion is no longer necessary and can be safely discontinued.

## Survey Procedures §482.13(f)(2)(v)

Does the hospital educational program address identification of specific behavioral changes that may indicate that restraint or seclusion is no longer necessary?

Interview staff to determine if they are able to demonstrate the abilities addressed in this requirement.

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance"], "logic_config": {"required_artifact": "staff competency in identifying behavioral changes for discontinuing restraint or seclusion"}, "rule_type": "existence", "scope_tags": ["clinical", "facility"]}
Guideline text:
Routine use of a UFH bolus (weight-adjusted i.v. bolus during PCI of 70–100 IU/kg) is recommended in patients undergoing PCI.

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"required_artifact": "UFH bolus", "trigger_assertion": "patient undergoing PCI"}, "rule_type": "conditional_existence", "scope_tags": ["clinical"]}
Guideline text:
(Rev. 37, Issued:  10-17-08; Effective/Implementation Date:  10-17-08)

§482.51(b)(6) - An operative report describing techniques, findings, and tissues removed or altered must be written or dictated immediately following surgery and signed by the surgeon.

## Interpretive Guidelines §482.51(b)(6)

The operative report includes at least:

- Name and hospital identification number of the patient;
- Date and times of the surgery;
- Name(s) of the surgeon(s) and assistants or other practitioners who performed surgical tasks (even when performing those tasks under supervision);
- Pre-operative and post-operative diagnosis;
- Name of the specific surgical procedure(s) performed;
- Type of anesthesia administered;
- Complications, if any;
- A description of techniques, findings, and tissues removed or altered;
- Surgeons or practitioners name(s) and a description of the specific significant surgical tasks that were conducted by practitioners other than the primary surgeon/practitioner (significant surgical procedures include:  opening and closing, harvesting grafts, dissecting tissue, removing tissue, implanting devices, altering tissues); and
- Prosthetic devices, grafts, tissues, transplants, or devices implanted, if any.

## Survey Procedures §482.51(b)(6)

Review a minimum of six random medical records of patients who had a surgical encounter.  Verify that they contain a surgical report that is dated and signed by the responsible surgeon and includes the information specified in the interpretive guidelines.

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance", "integrity"], "logic_config": {"required_artifact": {"name": "operative report", "required_content_elements": ["patient name and hospital identification number", "date and times of the surgery", "name(s) of the surgeon(s) and assistants or other practitioners who performed surgical tasks", "pre-operative and post-operative diagnosis", "name of the specific surgical procedure(s) performed", "type of anesthesia administered", "complications, if any", "description of techniques, findings, and tissues removed or altered", "surgeons or practitioners name(s) and a description of the specific significant surgical tasks that were conducted by practitioners other than the primary surgeon/practitioner", "prosthetic devices, grafts, tissues, transplants, or devices implanted, if any"], "signature_required_by": "surgeon", "timing_constraint": "immediately following surgery"}, "trigger_assertion": "surgery performed"}, "rule_type": "conditional_existence", "scope_tags": ["clinical", "legal"]}
Guideline text:
O2 Saturation must be above 94.

Structured rule (JSON):
{"intent_tags": ["safety"], "logic_config": {"min_value": 94, "target_vital": "O2 Saturation"}, "rule_type": "threshold", "scope_tags": ["clinical"]}
Guideline text:
Medication administration record must be recorded in chronological sequence.

Structured rule (JSON):
{"intent_tags": ["integrity"], "logic_config": {"event_type": "medication_administration_record"}, "rule_type": "monotonic", "scope_tags": ["clinical"]}
Guideline text:
Immediate coronary angiography and PCI of the IRA (if indicated) is recommended in patients with CS complicating ACS.

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"required_artifact": "Immediate coronary angiography and PCI of the IRA", "trigger_assertion": "CS complicating ACS"}, "rule_type": "conditional_existence", "scope_tags": ["clinical"]}
Guideline text:
Transfer to a PCI-capable centre is recommended in all patients immediately after fibrinolysis.

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"anchor": "fibrinolysis", "max_delay_minutes": 0, "target": "Transfer to a PCI-capable centre"}, "rule_type": "temporal", "scope_tags": ["clinical"]}
Guideline text:
A fibrin-specific agent (i.e. tenecteplase, alteplase, or reteplase) is recommended.

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"required_artifact": "fibrin-specific agent (tenecteplase, alteplase, or reteplase)"}, "rule_type": "existence", "scope_tags": ["clinical"]}
Guideline text:
Anesthesia record must be recorded in chronological sequence.

Structured rule (JSON):
{"intent_tags": ["integrity"], "logic_config": {"event_type": "anesthesia_record"}, "rule_type": "monotonic", "scope_tags": ["clinical"]}
Guideline text:
(Rev. 87, Issued: 07-19-13, Effective: 07-19-13, Implementation: 07-19-13)

§482.43(b)(6) - [The hospital must] include the discharge planning evaluation in the patient's medical record for use in establishing an appropriate discharge plan….

## Interpretive Guidelines §482.43(b)(6)

The hospital must include the discharge planning evaluation in the patient's medical record in order for it to guide the development of the patient's discharge plan.  Timely placement of the evaluation in the medical record facilitates communication among members of the patient's healthcare team who should participate in a multidisciplinary process to develop and implement the discharge plan.  The evaluation and subsequent planning process may be a continuous one and hospitals may choose not to divide the process into distinct documents.  The key requirement is that the evaluation results are included in the patient's medical record and are used in the development of the features of the discharge plan.

## Survey Procedures §482.43(b)(6)

- Review a sample of cases to determine if the discharge planning evaluation results are included in the medical record.

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance", "integrity"], "logic_config": {"required_artifact": "discharge planning evaluation results in the medical record"}, "rule_type": "existence", "scope_tags": ["clinical", "facility", "legal"]}
Guideline text:
(Rev. 183, Issued: 10-12-18, Effective: 10-12-18, Implementation: 10-12-18)

## §482.58(b)(4) Patient activities (§483.24(c))

- §483.24(c): Activities
- (1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.
- (2) The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who-
- (i) Is licensed or registered, if applicable, by the State in which practicing; and
- (ii) Is:
- (A) Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990; or
- (B) Has 2 years of experience in a social or recreational program within the last 5 years, one of which was full-time in a therapeutic activities program; or
- (C) Is a qualified occupational therapist or occupational therapy assistant; or
- (D) Has completed a training course approved by the State.

## Interpretive Guidelines §482.58(b)(4)

Refer to Appendix PP of the State Operations Manual (SOM) for interpretive guidelines.

## Survey Procedures §482.58(b)(4)

Refer to Appendix PP of the State Operations Manual (SOM) for survey procedures.

Structured rule (JSON):
{"intent_tags": ["quality", "compliance"], "logic_config": {"required_artifact": "qualified professional to direct activities program"}, "rule_type": "existence", "scope_tags": ["facility", "legal"]}
Guideline text:
O2 Saturation must be above 98.

Structured rule (JSON):
{"intent_tags": ["safety"], "logic_config": {"min_value": 98, "target_vital": "O2 Saturation"}, "rule_type": "threshold", "scope_tags": ["clinical"]}
Guideline text:
(Rev. 37, Issued:  10-17-08; Effective/Implementation Date:  10-17-08)

[At a minimum:]

§482.13(a)(2)(ii) The grievance process must specify time frames for review of the grievance and the provision of a response.

## Interpretive Guidelines §482.13(a)(2)(ii)

The hospital must review, investigate, and resolve each patient's grievance within a reasonable time frame.  For example, grievances about situations that endanger the patient, such as neglect or abuse, should be reviewed immediately, given the seriousness of the allegations and the potential for harm to the patient(s).  However, regardless of the nature of the grievance, the hospital should make sure that it is responding to the substance of each grievance while identifying, investigating, and resolving any deeper, systemic problems indicated by the grievance.

Document when a grievance is so complicated that it may require an extensive investigation.  We recognize that staff scheduling as well as fluctuations in the numbers and complexity of grievances can affect the timeframes for the resolution of a grievance and the provision of a written response.  On average, a time frame of 7 days for the provision of the response would be considered appropriate.  We do not require that every grievance be resolved during the specified timeframe although most should be resolved.  42 CFR 482.13(a)(2)(iii) specifies information the hospital must include in their response.

If the grievance will not be resolved, or if the investigation is not or will not be completed within 7 days, the hospital should inform the patient or the patient's representative that the hospital is still working to resolve the grievance and that the hospital will follow-up with a written response within a stated number of days in accordance with the hospital's grievance policy.  The hospital must attempt to resolve all grievances as soon as possible.

## Survey Procedures §482.13(a)(2)(ii)

What time frames are established to review and respond to patient grievances?  Are these time frames clearly explained in the information provided to the patient that explains the hospital's grievance process?  On average, does the hospital provide a written response to most of its grievances within the timeframe specified in its policy?

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance"], "logic_config": {"anchor": "grievance receipt", "max_delay_days": 7, "target": "grievance response"}, "rule_type": "temporal", "scope_tags": ["facility", "legal"]}
Guideline text:
It is recommended that patients transferred for PPCI bypass the emergency department and CCU/ICU and are transferred directly to the catheterization laboratory. 137 , 175 – 178

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"required_artifact": "transfer to catheterization laboratory directly, bypassing emergency department and CCU/ICU", "trigger_assertion": "patient transferred for PPCI"}, "rule_type": "conditional_existence", "scope_tags": ["clinical", "facility"]}
Guideline text:
Aspirin is recommended for all patients without contraindications at an initial oral LD of 150–300 mg (or 75–250 mg i.v.) and an MD of 75–100 mg o.d. for long-term treatment.

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"required_artifact": "Aspirin therapy"}, "rule_type": "existence", "scope_tags": ["clinical"]}
Guideline text:
Limit nebulizer treatment to 7 units per session.

Structured rule (JSON):
{"intent_tags": ["safety"], "logic_config": {"event_type": "nebulizer", "max_count": 7}, "rule_type": "count_sanity", "scope_tags": ["clinical"]}
Guideline text:
Cannot bill MRI with Contrast and MRI without Contrast on the same service date.

Structured rule (JSON):
{"intent_tags": ["compliance"], "logic_config": {"event_1": "MRI with Contrast", "event_2": "MRI without Contrast"}, "rule_type": "exclusive", "scope_tags": ["billing"]}
Guideline text:
Limit consultation to 2 units per session.

Structured rule (JSON):
{"intent_tags": ["safety"], "logic_config": {"event_type": "consultation", "max_count": 2}, "rule_type": "count_sanity", "scope_tags": ["clinical"]}
Guideline text:
(Rev. 200, Issued: 02-21-20; Effective: 02-21-20, Implementation: 02-21-20)

## §482.42(c)(3) Standard:  Leadership responsibilities

(3)  The leader(s) of the antibiotic stewardship program is responsible for: (i)  The development and implementation of a hospital-wide antibiotic stewardship program, based on nationally recognized guidelines, to monitor and improve the use of antibiotics.

## Interpretive Guidelines §482.42(c)(3)(i)

Guidance is pending and will be updated in future release.

A-0779

## (Rev. 200, Issued: 02-21-20; Effective: 02-21-20, Implementation: 02-21-20) [§482.42(c)(3)  The leader(s) of the antibiotic stewardship program is responsible for:]

(ii)  All documentation, written or electronic, of antibiotic stewardship program activities.

## Interpretive Guidelines §482.42(c)(3)(ii)

Guidance is pending and will be updated in future release.

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance"], "logic_config": {"required_artifact": "hospital-wide antibiotic stewardship program"}, "rule_type": "existence", "scope_tags": ["clinical", "facility"]}