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

§482.61(a) Standard: Development of Assessment/Diagnostic Data  Medical records must stress the psychiatric components of the record, including history of findings and treatment provided for the psychiatric condition for which the patient is hospitalized.

## Interpretive Guidelines §482.61(a)

Guidance is pending and will be updated in future release.

A-1622

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

§482.61(a)(1) The identification data must include the patient's legal status.

## Interpretive Guidelines §482.61(a)(1)

Definition: Legal Status is defined in the State statutes and dictates the circumstances under which the patient was admitted and/or is being treated - i.e., voluntary, involuntary, committed by court, evaluation and recertification are in accordance with state requirements.

Determine through interview with hospital staff the terminology they use in defining 'legal status.' If evaluation and recertification is required by the State, determine that legal documentation supporting this status is present. Changes in legal status should also be recorded with the date of change.

A-1623

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

§482.61(a)(2) A provisional or admitting diagnosis must be made on every patient at the time of admission, and must include the diagnosis of intercurrent diseases as well as the psychiatric diagnosis.

## Interpretive Guidelines §482.61(a)(2)

There is an admission or working psychiatric diagnosis (including rule-out diagnoses) written in the most current edition of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM) or the approved International Classification of Diseases (ICD) nomenclature. This diagnosis is made and entered into the chart of each patient at the time of the admission examination. The final diagnosis may differ from the initial diagnosis if subsequent evaluation and observation support a change.

If a diagnosis is absent, there must be justification for its absence. For example, if a patient was psychotic on admission and was not accompanied by family or significant others.

Intercurrent (other than psychiatric) diagnoses must be documented when they are made. Attention should be paid to physical examination notes, including known medical conditions, even allergies and recent exposure to infections, illness, or substance abuse, and to available laboratory or test reports which identify abnormal findings to see that these are reflected by appropriate diagnosis.

These diagnoses may be found in a variety of locations in the medical record, e.g., the identification/face sheet, the finding of admission physical examination, the psychiatric evaluation the 'admission work up ' or the physician's progress notes. Diagnostic categories should include physical illness when present.

## Survey Procedures §482.61(a)(2)

Are abnormal physical examination findings and/or laboratory findings justified by further diagnostic testing and/or development of an intercurrent diagnosis, and, if so, was such done?

If an identified physical illness requires immediate treatment, is the treatment being given?

How will an identified physical illness be likely to impact on the patient's eventual outcome? To what extent has this potential impact been addressed by the team?

Structured rule (JSON):
{"intent_tags": ["compliance", "quality", "integrity"], "logic_config": {"required_artifact": "detailed psychiatric components in the medical record, including history of findings and treatment provided for the psychiatric condition"}, "rule_type": "existence", "scope_tags": ["clinical", "legal"]}