CMS Requirements for Medical Record Services

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.