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10. Medical Records

 
 
(Rev. 95, Issued: 12-12-13, Effective: 06-07-13, Implementation: 06-07-13)
 
§416.47 Condition for Coverage: Medical Records
 
The ASC must maintain complete, comprehensive, and accurate medical records to ensure adequate patient care.
 
Interpretive Guidelines: §416.47
 
The ASC must have a complete, comprehensive and accurate medical record for each patient. Material required under other Conditions, such as the history and physical examination or documentation of allergies to drugs and biologicals required under §416.52, must be incorporated into the medical record in a timely fashion. The ASC must use the information contained in each medical record in order to assure that adequate care is delivered to each ASC patient. In accordance with the provisions of the Patients’ Rights Condition at §416.50(g), the ASC must ensure the confidentiality of each patient’s medical record.
 
Survey Procedures: §416.47
 
Review a sample of active and closed medical records for completeness and accuracy in accordance with Federal and State laws and regulations and ASC policy. If patient records are not collected in a systematic manner for easy access, annotate this on the survey report form.
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