CMS Requirements for Medical Record Services
by Chad Niemeyer, from the Community
Use this checklist to assess compliance with CMS Conditions of Participation for Medical Record Services under 42 CFR 482.24. Covering A-tags for hospitals and B-tags for psychiatric hospitals, it guides reviews of service organization and staffing, form and retention, confidentiality and access, content completeness, legibility, dating and authentication, verbal and standing orders, medical history and physical timing, coding and indexing, discharge summaries, final diagnoses, and psychiatric evaluation and treatment plan standards. Ensure policies, documentation, and survey readiness across inpatient and outpatient settings.
With SafetyCulture you can
Digitize team workflows
Turn your workflows into digital templates or checklists so your team can conduct inspections efficiently and access them from any device.
Reduce manual errors
Help your team complete tasks more accurately with digital templates that minimize errors from manual processes.
Create and share inspection reports
Generate inspection reports and share them with your team and stakeholders to keep everyone informed.
About author
This community page makes available free workplace checklists and templates created by other users within the SafetyCulture community. SafetyCulture has re-published this content and where possible, has credited the original author. SafetyCulture has not verified the accuracy, reliability or suitability of any community content. You agree that your use of any of this content is in accordance with SafetyCulture’s Terms and Conditions.