Development of Assessment/Diagnostic Data

30.1 - Development of Assessment/Diagnostic Data (Rev. 253, Issued: 12- 14-18, Effective: 01-16-19, Implementation: 01- 16-19) In accordance with 42 CFR 412.27(c) and 42 CFR 482.61(a), medical records must stress the psychiatric components of the record, including history of findings and treatment provided for the psychiatric condition for which the patient is hospitalized. (1) The identification data must include the patient’s legal status. According to the Interpretative Guidelines for 482.61(a)(1) given in the State Operations Manual (SOM; see IOM 100-07, Appendix AA), legal status is defined in the State statutes and dictates the circumstances under which the patient was admitted and/or is being treated - i.e., voluntary, involuntary, committed by court, evaluation and recertification are in accordance with State requirements. (2) A provisional or admitting diagnosis must be made on every patient at the time of admission, and must include the diagnoses of comorbid conditions as well as the psychiatric diagnoses. (3) The reasons for admission must be clearly documented as stated by the patient and/or others significantly involved. (4) The social service records, including reports of interviews with patients, family members, and others, must provide an assessment of home plans and family attitudes, and community resource contacts as well as a social history. (5) When indicated, a complete neurological examination must be recorded at the time of the admission physical examination.