---
kind: "section"
citation: "42 C.F.R. § 416.47"
title: "42"
number: "416.47"
heading: "Condition for coverage—Medical records."
url: "https://uscodex.org/cfr/42/416.47"
---

# §416.47. Condition for coverage—Medical records.


The ASC must maintain complete, comprehensive, and accurate medical records to ensure adequate patient care.

- (a) **Standard: Organization.** The ASC must develop and maintain a system for the proper collection, storage, and use of patient records.
- (b) **Standard: Form and content of record.** The ASC must maintain a medical record for each patient. Every record must be accurate, legible, and promptly completed. Medical records must include at least the following:
  - (1) **Patient identification.**
  - (2) **Significant medical history and results of physical examination (as applicable).**
  - (3) **Pre-operative diagnostic studies (entered before surgery), if performed.**
  - (4) Findings and techniques of the operation, including a pathologist's report on all tissues removed during surgery, except those exempted by the governing body.
  - (5) **Any allergies and abnormal drug reactions.**
  - (6) **Entries related to anesthesia administration.**
  - (7) **Documentation of properly executed informed patient consent.**
  - (8) **Discharge diagnosis.**

## Notes

### Amendments

[47 FR 34094, Aug. 5, 1982, as amended at 84 FR 51814, Sept. 30, 2019]

### Authority

Authority: 42 U.S.C. 273, 1302, 1320b-8, and 1395hh.

### Source

Source: 47 FR 34094, Aug. 5, 1982, unless otherwise noted.

### Amendments

[47 FR 34094, Aug. 5, 1982, as amended at 84 FR 51814, Sept. 30, 2019]