42 CFR § 460.210 - Medical records.
(a) Maintenance of medical records.
(2) The medical record for each participant must meet the following requirements:
(i) Be complete.
(ii) Accurately documented.
(iii) Readily accessible.
(iv) Systematically organized.
(v) Available to all staff.
(b) Content of medical records. At a minimum, the medical record must contain the following:
(1) Appropriate identifying information.
(2) Documentation of all services furnished, including the following:
(iii) Services furnished by contractors and their reports.
(3) Interdisciplinary assessments, reassessments, plans of care, treatment, and progress notes that include the participant's response to treatment.
(5) If a service recommended by an employee or contractor of the PACE organization, including a specialist, is not approved or provided, the reason(s) for not approving or providing that service.
(6) Original documentation, or an unaltered electronic copy, of any written communication the PACE organization receives relating to the care, health or safety of a participant, in any format (for example, emails, faxes, letters, etc.) and including, but not limited to the following:
(i) Communications from the participant, his or her designated representative, a family member, a caregiver, or any other individual who provides information pertinent to a participant's health or safety or both.
(ii) Communications from an advocacy or governmental agency such as Adult Protective Services.
(7) Laboratory, radiological and other test reports.
(8) Medication records.
(9) Hospital discharge summaries, if applicable.
(10) Reports of contact with informal support (for example, caregiver, legal guardian, or next of kin).
(11) Enrollment Agreement.
(12) Physician orders.
(13) Discharge summary and disenrollment justification, if applicable.
(14) Advance directives, if applicable.
(15) A signed release permitting disclosure of personal information.
(c) Transfer of medical records. The organization must promptly transfer copies of medical record information between treatment facilities.
(d) Authentication of medical records.
(1) All entries must be legible, clear, complete, and appropriately authenticated and dated.
(2) Authentication must include signatures or a secured computer entry by a unique identifier of the primary author who has reviewed and approved the entry.
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