---
kind: "section"
citation: "42 C.F.R. § 416.52"
title: "42"
number: "416.52"
heading: "Conditions for coverage—Patient admission, assessment and discharge."
url: "https://uscodex.org/cfr/42/416.52"
---

# §416.52. Conditions for coverage—Patient admission, assessment and discharge.


The ASC must ensure each patient has the appropriate pre-surgical and post-surgical assessments completed and that all elements of the discharge requirements are completed.

- (a) **Standard: Patient assessment and admission.**
  - (1) The ASC must develop and maintain a policy that identifies those patients who require a medical history and physical examination prior to surgery. The policy must—
    - (i) **Include the timeframe for medical history and physical examination to be completed prior to surgery.**
    - (ii) **Address, but is not limited to, the following factors—** Patient age, diagnosis, the type and number of procedures scheduled to be performed on the same surgery date, known comorbidities, and the planned anesthesia level.
    - (iii) Be based on any applicable nationally recognized standards of practice and guidelines, and any applicable State and local health and safety laws.
  - (2) Upon admission, each patient must have a pre-surgical assessment completed by a physician who will be performing the surgery or other qualified practitioner in accordance with applicable State health and safety laws, standards of practice, and ASC policy.
  - (3) The pre-surgical assessment must include documentation of any allergies to drugs and biologicals.
  - (4) The patient's medical history and physical examination (if any) must be placed in the patient's medical record prior to the surgical procedure.
- (b) **Standard: Post-surgical assessment.**
  - (1) The patient's post-surgical condition must be assessed and documented in the medical record by a physician, other qualified practitioner, or a registered nurse with, at a minimum, post-operative care experience in accordance with applicable State health and safety laws, standards of practice, and ASC policy.
  - (2) Post-surgical needs must be addressed and included in the discharge notes.
- (c) **Standard: Discharge.** The ASC must—
  - (1) **Provide each patient with written discharge instructions and overnight supplies.** When appropriate, make a followup appointment with the physician, and ensure that all patients are informed, either in advance of their surgical procedure or prior to leaving the ASC, of their prescriptions, post-operative instructions and physician contact information for followup care.
  - (2) Ensure each patient has a discharge order, signed by the physician who performed the surgery or procedure in accordance with applicable State health and safety laws, standards of practice, and ASC policy.
  - (3) Ensure all patients are discharged in the company of a responsible adult, except those patients exempted by the attending physician.

## Notes

### Amendments

[73 FR 68813, Nov. 18, 2008, 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

[73 FR 68813, Nov. 18, 2008, as amended at 84 FR 51814, Sept. 30, 2019]