The following providers must maintain central clinical records on all patients:
· Hospice programs;5
· Home health agencies;6
· Clinics and rehabilitation agencies providing outpatient physical therapy services;7
· Rural health clinics must maintain clinical records on all patients;8
· Comprehensive outpatient rehabilitation facilities;9
· Hospitals;10
· Psychiatric hospitals;11 and
· SNFs.12
In addition, every individual and organization providing services to Medicare beneficiaries must document in the individual’s medical record whether or not the individual has executed an advance directive.13
Footnotes
- 5. Social Security Act § 1861(dd)(2)(C), 42 U.S.C. 1395x(dd)(2)(C).
- 6. Social Security Act § 1861(o)(3), 42 U.S.C. 1395x(o)(3).
- 7. Social Security Act § 1861(p)(4)(A)(iii), 42 U.S.C. 1395x(p)(4)(A)(iii).
- 8. Social Security Act § 1861(aa)(2)(C), 42 U.S.C. 1395x(aa)(2)(C).
- 9. Social Security Act § 1861(cc)(2)(G), 42 U.S.C. 1395x(cc)(2)(G).
- 10. Social Security Act § 1861(e)(2), 42 U.S.C. 1395x(e)(2).
- 11. Social Security Act § 1861(f)(3), 42 U.S.C. 1395x(f)(3).
- 12. Social Security Act § 1819(b)(6)(C), 42 U.S.C. 1395i-3(b)(6)(C).
- 13. Social Security Act § 1866(f)(1)(B), 42 U.S.C. 1395cc(f)(1)(B).
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