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Critical Access Hospital
Record of Care, Treatment, and Services (RC) Standards
RC.01.03.01 Documentation in the medical record is entered in a timely manner.
EP3 History and physical examination updates
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Record of Care, Treatment, and Services (RC) Standards
RC.01.01.01 The critical access hospital maintains complete and accurate medical records for each individual patient.
EP1 Components of the medical record
EP5 Information on the medical record
EP7 Dated entries
RC.01.03.01 Documentation in the medical record is entered in a timely manner.
EP3 History and physical examination updates
RC.02.01.01 The medical record contains information that reflects the patient's care, treatment, and services.
EP2 Clinical information
RC.02.01.03 The patient's medical record contains documentation on any operative or other high-risk procedures and the use of moderate or deep sedation or anesthesia.
EP1 Operative or other high-risk procedures
EP2 Provisional diagnosis
EP3 History and physical for a high-risk procedure
EP5 Operative report
EP6 Operative report information
EP7 Operative progress note
EP8 Postoperative information
EP9 Post-sedation or postanesthesia care
EP10 Discharge criteria
EP11 Practitioner responsible for discharge
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Element of Performance
Record the patient's medical history and physical examination, including updates, in the medical record within 24 hours after registration or inpatient admission but prior to surgery or a procedure requiring anesthesia services.
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