Nick-Maximillien/medgate-compiler-data huggingface dataset:
Guideline text:
## §482.24 Condition of Participation:  Medical Record Services

The hospital must have a medical record service that has administrative responsibility for medical records.  A medical record must be maintained for every individual

## evaluated or treated in the hospital.

## Interpretive Guidelines §482.24

The term 'hospital' includes all locations of the hospital.

The hospital must have one unified medical record service that has administrative responsibility for all medical records, both inpatient and out patient records.  The hospital must create and maintain a medical record for every individual, both inpatient and out patient evaluated or treated in the hospital.

The term ' medical records ' includes at least written documents, computerized electronic information, radiology film and scans, laboratory reports and pathology slides, videos, audio recordings, and other forms of information regarding the condition of a patient.

## Survey Procedures §482.24

- Review the organizational structure and policy statements and interview the person responsible for the medical records service to ascertain that the service is structured appropriately to meet the needs of the hospital and the patients.
- Review a sample of active and closed medical records for completeness and accuracy in accordance with Federal and State laws and regulations and hospital policy.  The sample should be 10 percent of the average daily census and be no less than 30 records.  Additionally, select a sample of outpatient records in order to determine compliance in outpatient departments, services, and locations.

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance", "integrity"], "logic_config": {"required_artifact": "medical record", "scope_condition": "for every individual evaluated or treated in the hospital"}, "rule_type": "existence", "scope_tags": ["clinical", "facility", "legal"]}
Guideline text:
(Rev. 200, Issued: 02-21-20; Effective: 02-21-20, Implementation: 02-21-20)

## §482.43(a)(4) Standard: Discharge Planning Process

(4) Upon the request of a patient's physician, the hospital must arrange for the development and initial implementation of a discharge plan for the patient.

## Interpretive Guidelines §482.43(a)(4)

Guidance is pending and will be updated in future release.

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance"], "logic_config": {"required_artifact": "arrangement for the development and initial implementation of a discharge plan for the patient", "trigger_assertion": "request of a patient's physician"}, "rule_type": "conditional_existence", "scope_tags": ["clinical", "facility", "legal"]}
Guideline text:
Combination therapy with a high-dose statin plus ezetimibe may be considered during index hospitalization.

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"required_artifact": "consideration of combination therapy with high-dose statin plus ezetimibe during index hospitalization"}, "rule_type": "existence", "scope_tags": ["clinical"]}
Guideline text:
When enoxaparin is not available, UFH is recommended as a weight-adjusted i.v. bolus, followed by infusion. 357

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"required_artifact": "UFH administration (weight-adjusted i.v. bolus, followed by infusion)", "trigger_assertion": "enoxaparin not available"}, "rule_type": "conditional_existence", "scope_tags": ["clinical"]}
Guideline text:
Evaluation of neurological prognosis (no earlier than 72 h after admission) is recommended in all comatose survivors after cardiac arrest. 386

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"anchor": "admission", "min_delay_hours": 72, "target": "Evaluation of neurological prognosis"}, "rule_type": "temporal", "scope_tags": ["clinical"]}
Guideline text:
Pacing is not recommended if high-degree AV block resolves after revascularization or spontaneously.

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:
Adding a second antithrombotic agent to aspirin for extended long-term secondary prevention may be considered in patients with moderate ischaemic risk and without HBR c . 314 – 318

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"required_artifact": "consideration of adding a second antithrombotic agent to aspirin for extended long-term secondary prevention", "trigger_assertion": "patient has moderate ischaemic risk and is without high bleeding risk (HBR)"}, "rule_type": "conditional_existence", "scope_tags": ["clinical"]}
Guideline text:
Cardiovascular disease is the leading cause of death globally. [Ref: 241]

Structured rule (JSON):
{"intent_tags": [], "logic_config": {}, "rule_type": "unsupported", "scope_tags": [], "summary": "Non-executable narrative text"}
Guideline text:
(Rev. 37, Issued:  10-17-08; Effective/Implementation Date:  10-17-08)

[…the governing body must ensure that the following requirements are met:]

§482.12(c)(1)  Every Medicare patient is under the care of:

- (i) A doctor of medicine or osteopathy.  (This provision is not to be construed to limit the authority of a doctor of medicine or osteopathy to delegate tasks to other qualified health care personnel to the extent recognized under State law or a State's regulatory mechanism.);
- (ii) A doctor of dental surgery or dental medicine who is legally authorized to practice dentistry by the State and who is acting within the scope of his or her license;

(iii)A doctor of podiatric medicine, but only with respect to functions which he or she is legally authorized by the State to perform;

- (iv) A doctor of optometry who is legally authorized to practice optometry by the State in which he or she practices;
- (v) A chiropractor who is licensed by the State or legally authorized to perform the services of a chiropractor, but only with respect to treatment by means of manual manipulation of the spine to correct a subluxation demonstrated by x-ray to exist; and
- (vi) A clinical psychologist as defined in §410.71 of this chapter, but only with respect to clinical psychologist services as defined in §410.71 of this chapter and only to the extent permitted by State law.

## Interpretive Guidelines §482.12(c)(1)

Practitioners other than doctors of medicine or osteopathy may join the medical staff if the practitioners are appropriately licensed and medical staff membership is in accordance with State law.

Every Medicare or Medicaid patient must be under the care of a licensed practitioner as defined in this requirement.

## Survey Procedures §482.12(c)(1)

Verify that Medicare patients are under the care of a licensed practitioner as defined by (c)(1).

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance"], "logic_config": {"required_artifact": "care by an authorized practitioner", "trigger_assertion": "Medicare or Medicaid patient"}, "rule_type": "conditional_existence", "scope_tags": ["clinical", "legal"]}
Guideline text:
(Rev. 200, Issued: 02-21-20; Effective: 02-21-20, Implementation: 02-21-20)

§482.60(a) Be primarily engaged in providing, by or under the supervision of a doctor of medicine or osteopathy, psychiatric services for the diagnosis and treatment of mentally ill persons.

## Interpretive Guidelines §482.60

The hospital will be deemed to meet standard (a) if it meets standards (c) and (d).

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance"], "logic_config": {"required_artifact": "hospital is primarily engaged in providing psychiatric services for diagnosis and treatment of mentally ill persons under supervision of a doctor of medicine or osteopathy", "trigger_assertion": "hospital meets standards (c) and (d)"}, "rule_type": "conditional_existence", "scope_tags": ["clinical", "facility", "legal"]}
Guideline text:
(Rev. 200, Issued: 02-21-20; Effective: 02-21-20, Implementation: 02-21-20)

§482.61(a)(3) The reasons for admission must be clearly documented as stated by the patient and/or others significantly involved.

## Interpretive Guidelines §482.61(a)(3)

The purpose of this regulation is to provide an understanding of what caused the patient to come to the hospital, and the patient's response to admission.

The hospital records the statements and reason for admission given by family and by others, as well as the patient (preferably verbatim), with informant identified, in a variety of locations, e.g., in transfer and admission notes from the physician, nurses and social workers.

Records should not contain vague, ill-defined reports from unknown sources. Records should record 'who,' 'what,' 'where,' 'when,' and 'why.'

## Survey Procedures §482.61(a)(3)

Can the patient describe problems, stresses, situations experienced prior to hospitalization or do they still exist?

Who is the informant?

Did the informant witness the patient's behavior? If not, on what basis has the informant come to know the patient's behavior?

Has staff elicited whether the patient has exhibited similar behavior previously? If so, what was different this time to make hospitalization necessary?

Were there other changes/events in the patient's environment (death, separations of significant others) which contributed to the need for hospitalization? If so, has staff explored how these will impact in the patient's treatment? Has this been addressed by the treatment team?

Has there been an interruption or change in the patient's medication which may have been a factor in the patient's hospitalization?

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance", "integrity"], "logic_config": {"artifact_attributes": {"clarity": "clearly documented", "prohibited_characteristics": ["vague reports", "ill-defined reports", "reports from unknown sources"], "required_elements": ["who", "what", "where", "when", "why"], "source_identification_required": true, "source_types": ["patient", "others significantly involved"]}, "required_artifact": "reasons for admission documentation"}, "rule_type": "existence", "scope_tags": ["clinical", "facility", "legal"]}
Guideline text:
(Rev. 37, Issued:  10-17-08; Effective/Implementation Date:  10-17-08)

§482.12(d)(6) The plan must be reviewed and updated annually

## Survey Procedures §482.12(d)(6)

Verify that the plan and budget are reviewed and updated annually.

Structured rule (JSON):
{"intent_tags": ["compliance", "quality", "integrity"], "logic_config": {"required_actions": ["reviewed", "updated"], "review_frequency": "annually", "target_protocol_or_document": "plan and budget"}, "rule_type": "protocol_validity", "scope_tags": ["facility", "legal"]}
Guideline text:
(Rev. 37, Issued:  10-17-08; Effective/Implementation Date:  10-17-08)

§482.27(a)(4) - The medical staff and a pathologist must determine which tissue specimens require a macroscopic (gross) examination and which require both macroscopic and microscopic examinations.

## Interpretive Guidelines §482.27(a)(4)

Laboratory written policies, approved by the medical staff and a pathologist, must state which tissue specimens require a macroscopic examination and which tissue specimens require both macroscopic and microscopic examination.

## Survey Procedures §482.27(a)(4)

- Verify that the hospital has a written policy for examination requirements.
- Review the written policies and tissue reports to assure that tissue specimens are examined in accordance with the written policies.
- Verify that the policies are in accordance with these requirements and other Federal and State laws, regulations, and guidelines.

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance"], "logic_config": {"required_artifact": "defined criteria and written policies for tissue specimen examination"}, "rule_type": "existence", "scope_tags": ["clinical", "facility", "legal"]}
Guideline text:
It is recommended that healthcare systems implement strategies to facilitate transfer of all patients in whom ACS is suspected after resuscitated cardiac arrest directly to a hospital offering 24/7 PPCI via one specialized EMS.

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"required_artifact": "transfer to a hospital offering 24/7 PPCI via one specialized EMS", "trigger_assertion": "ACS is suspected after resuscitated cardiac arrest"}, "rule_type": "conditional_existence", "scope_tags": ["clinical", "facility"]}
Guideline text:
(Rev. 200, Issued: 02-21-20; Effective: 02-21-20, Implementation: 02-21-20)

§482.41(b)(5) - The hospital must have written fire control plans that contain provisions for prompt reporting of fires; extinguishing fires; protection of patients, personnel and guests; evacuation; and cooperation with fire fighting authorities.

Survey Procedures §482.41(b)(5)

Guidance is pending and will be updated in future release.

Structured rule (JSON):
{"intent_tags": ["safety", "compliance"], "logic_config": {"plan_provisions": ["prompt reporting of fires", "extinguishing fires", "protection of patients, personnel and guests", "evacuation", "cooperation with fire fighting authorities"], "required_artifact": "written fire control plans"}, "rule_type": "existence", "scope_tags": ["facility", "legal"]}
Guideline text:
(Rev. 200, Issued: 02-21-20; Effective: 02-21-20, Implementation: 02-21-20)

§482.43(b) Standard: Discharge of the patient and the provision and transmission of the patient's necessary medical information.

The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient's follow-up or ancillary care.

## Interpretive Guidelines §482.43(b)

Guidance is pending and will be updated in future release.

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance"], "logic_config": {"required_artifact": "transfer of necessary medical information to post-acute care providers", "trigger_assertion": "patient discharge"}, "rule_type": "conditional_existence", "scope_tags": ["clinical", "facility", "legal"]}
Guideline text:
Reperfusion therapy is recommended in all patients with a working diagnosis of STEMI (persistent ST-segment elevation or equivalents) and symptoms of ischaemia of ≤12 h duration.

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"required_artifact": "Reperfusion therapy recommendation", "trigger_assertion": "working diagnosis of STEMI (persistent ST-segment elevation or equivalents) AND symptoms of ischaemia of \u226412 h duration"}, "rule_type": "conditional_existence", "scope_tags": ["clinical"]}
Guideline text:
Future research is needed to establish optimal thresholds. [Ref: 596]

Structured rule (JSON):
{"intent_tags": [], "logic_config": {}, "rule_type": "unsupported", "scope_tags": [], "summary": "Non-executable narrative text"}
Guideline text:
A PPCI strategy is recommended in patients with resuscitated cardiac arrest and an ECG with persistent ST-segment elevation (or equivalents).

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"required_artifact": "PPCI strategy", "trigger_assertion": "resuscitated cardiac arrest and an ECG with persistent ST-segment elevation (or equivalents)"}, "rule_type": "conditional_existence", "scope_tags": ["clinical"]}
Guideline text:
Cardiovascular disease is the leading cause of death globally. [Ref: 567]

Structured rule (JSON):
{"intent_tags": [], "logic_config": {}, "rule_type": "unsupported", "scope_tags": [], "summary": "Non-executable narrative text"}
Guideline text:
(Rev. 105, Issued: 03-21-14, Effective: 03-21-14, Implementation: 03-21-14)

Standard Tag for requirements found only in Condition stem statement

§482.21 Condition of Participation: Quality Assessment and Performance Improvement Program

… The hospital's governing body must ensure that the program reflects the complexity of the hospital's organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement)…   The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS.

Structured rule (JSON):
{"intent_tags": ["quality", "compliance", "safety"], "logic_config": {"required_artifact": "Quality Assessment and Performance Improvement Program (QAPI) and its documented evidence"}, "rule_type": "existence", "scope_tags": ["facility"]}
Guideline text:
(Rev. 200, Issued: 02-21-20; Effective: 02-21-20, Implementation: 02-21-20)

§482.13(e)(12) - When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1 hour after the initiation of the intervention --

- (i) By a -
- (A) Physician or other licensed practitioner; or
- (B) Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section.

## Interpretive Guidelines §482.13(e)(12)(i)

When restraint or seclusion is used to manage violent or self-destructive behavior, a physician or other LP, or a registered nurse (RN) trained in accordance with the requirements specified under §482.13(f), must see the patient face-to-face within 1-hour after the initiation of the intervention. This requirement also applies when a drug or medication is used as a restraint to manage violent or self-destructive behavior.

The 1-hour face-to-face patient evaluation must be conducted in person by a physician or other LP, or trained RN.  A telephone call or telemedicine methodology is not permitted.

If a patient's violent or self-destructive behavior resolves and the restraint or seclusion intervention is discontinued before the practitioner arrives to perform the 1-hour face-toface evaluation, the practitioner is still required to see the patient face-to-face and conduct the evaluation within 1 hour after the initiation of this intervention.  The fact that the patient's behavior warranted the use of a restraint or seclusion indicates a serious medical or psychological need for prompt evaluation of the patient behavior that led to the intervention.  The evaluation would also determine whether there is a continued need for the intervention, factors that may have contributed to the violent or self-destructive behavior, and whether the intervention was appropriate to address the violent or selfdestructive behavior.

EXCEPTION:

Repetitive self-mutilating behaviors - see interpretive guidance for §482.13(e)(6).

## Survey Procedures §482.13(e)(12)(i)

- Review the hospital policy regarding the 1-hour face-to-face evaluation.
- What categories of practitioners does the hospital policy authorize to conduct the 1hour face-to-face evaluation?
- Interview staff to determine if practice is consistent with hospital policy.

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance"], "logic_config": {"anchor": "initiation of restraint or seclusion intervention", "evaluation_method": "in-person", "max_delay_minutes": 60, "required_actor_roles": ["Physician", "Licensed Practitioner", "Trained Registered Nurse"], "target": "face-to-face evaluation by qualified personnel", "trigger_condition": "restraint or seclusion used for violent/self-destructive behavior"}, "rule_type": "temporal", "scope_tags": ["clinical", "legal"]}
Guideline text:
(Rev. 141, Issued: 07-10-15, Effective: 07-10-15, Implementation: 07-10-15)

§482.26(b)(1) - Proper safety precautions must be maintained against radiation hazards. This includes adequate shielding for patients, personnel, and facilities, as well as appropriate storage, use and disposal of radioactive materials.

## Interpretive Guidelines §482.26(b)(1)

The hospital must adopt and implement written policies and procedures to ensure safety from radiation hazards.  The policies and procedures must include, but are not limited to, consideration of the following:

- Clear and easily recognizable signage identifying hazardous radiation  areas;
- Limitations on access to areas containing radiologic services equipment.
- Appropriate use of shielding, including:
- Types of personal protective shielding (e.g., lead aprons, lead gloves, protective eyewear, thyroid shields, portable individualized lead panels, stationary barriers) to be used, under what circumstances, for patients, including high-risk patients as identified in radiologic services policies and procedures, patient family members or support persons who may be needed to be with the patient during a study or procedure, and hospital personnel;
- Lead and concrete barriers built into the walls and other structures of the imaging areas;
- Identification and use of appropriate containers to be used for various radioactive materials, if applicable, when stored, in transport between locations within the hospital, in use, and during/after disposal.

## For Information Only - Not Required/ Not to be Cited

The Occupational Health and Safety Administration (OSHA) has requirements for protecting hospital staff from radiation exposure, some of which are summarized below:

- 'For information about exposure limits see:  29 CFR 1910.1096, Ionizing Radiation Standard.  The standard also requires:
- Each radiation area shall be conspicuously posted with a sign or signs bearing the radiation caution symbol, with the wording 'Caution Radiation Area' [29 CFR 1910.1096(e)(2)]'

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## Survey Procedures §482.26(b)(1)

- Verify that personal shielding, supplies and equipment are properly maintained and routinely inspected by the hospital.
- Determine if the proper shielding is applied to a patient who is undergoing a procedure using ionizing radiation.
- Determine if staff members appropriately extricate themselves from the immediate exposure field while performing a study or procedure using ionizing radiation.
- Determine if staff wear shielding as appropriate, per hospital policy.
- Verify that any hazardous radiation materials are clearly labeled, properly stored in a safe manner in the requisite containers, and disposed of in the appropriate manner.

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance"], "logic_config": {"required_artifact": "written radiation safety policies and procedures and their implementation"}, "rule_type": "existence", "scope_tags": ["clinical", "facility", "legal"]}
Guideline text:
De-escalation of P2Y 12 receptor inhibitor treatment (e.g. with a switch from prasugrel/ticagrelor to clopidogrel) may be considered as an alternative DAPT strategy to reduce bleeding risk. 279 – 282 , 321 , 322

Structured rule (JSON):
{"intent_tags": ["safety", "quality"], "logic_config": {"required_artifact": "consideration of de-escalation of P2Y12 receptor inhibitor treatment (e.g., switch from prasugrel/ticagrelor to clopidogrel) as an alternative DAPT strategy", "trigger_assertion": "patient requires reduction in bleeding risk"}, "rule_type": "conditional_existence", "scope_tags": ["clinical"]}
Guideline text:
Clinicians should use their best judgment when applying these rules. [Ref: 336]

Structured rule (JSON):
{"intent_tags": [], "logic_config": {}, "rule_type": "unsupported", "scope_tags": [], "summary": "Non-executable narrative text"}
Guideline text:
Limit EKG interpretation to 2 units per session.

Structured rule (JSON):
{"intent_tags": ["safety"], "logic_config": {"event_type": "ekg", "max_count": 2}, "rule_type": "count_sanity", "scope_tags": ["clinical"]}