The hospital maintains complete and accurate medical records for each individual patient.

(1)

The hospital maintains a medical record for every inpatient and outpatient in the hospital.

(2)

The medical record includes the following: - Information needed to justify the patient’s admission and continued care, treatment, and services - Information needed to support the patient’s diagnosis and condition - Information about the patient’s care, treatment, and services that promotes continuity of care among staff and providers Note: For hospitals that elect Joint Commission's Primary Care Medical Home option: This requirement refers to care provided by both internal and external providers.

(3)

The medical record of a patient who receives urgent or immediate care, treatment, and services contains all of the following: - Time and means of arrival - Indication that the patient left against medical advice, when applicable - Conclusions reached at the termination of care, treatment, and services, including the patient's final disposition, condition, and instructions given for follow-up care, treatment, and services - A copy of any information made available to the provider furnishing follow-up care, treatment, or services

(4)

The hospital develops and implements policies and procedures for accurate, legible, complete, signed, dated, and timed medical record entries that are authenticated by the person responsible for providing or evaluating the service provided. The medical records are promptly completed, properly filed and retained, and readily accessible.