---
kind: "section"
citation: "42 C.F.R. § 460.210"
title: "42"
number: "460.210"
heading: "Medical records."
url: "https://uscodex.org/cfr/42/460.210"
---

# §460.210. Medical records.

- (a) **Maintenance of medical records.**
  - (1) A PACE organization must maintain a single, comprehensive medical record for each participant, in accordance with accepted professional standards.
  - (2) The medical record for each participant must meet the following requirements:
    - (i) **Be complete.**
    - (ii) **Accurately documented.**
    - (iii) **Readily accessible.**
    - (iv) **Systematically organized.**
    - (v) **Available to all staff.**
    - (vi) **Maintained and housed at the PACE center where the participant receives services.**
- (b) **Content of medical records.** At a minimum, the medical record must contain the following:
  - (1) **Appropriate identifying information.**
  - (2) **Documentation of all services furnished, including the following—**
    - (i) **A summary of emergency care and other inpatient or long-term care services.**
    - (ii) **Services furnished by employees of the PACE center.**
    - (iii) **Services furnished by contractors and their reports.**
  - (3) Interdisciplinary assessments, reassessments, plans of care, treatment, and progress notes that include the participant's response to treatment.
  - (4) All recommendations for services made by employees or contractors of the PACE organization, including specialists.
  - (5) If a service recommended by an employee or contractor of the PACE organization, including a specialist, is not approved or provided, the reason(s) for not approving or providing that service.
  - (6) Original documentation, or an unaltered electronic copy, of any written communication as described in [§ 460.200(d)(2)](/cfr/42/460.200.md?p=d-2) must be maintained in the participant's medical record unless the following requirements are met:
    - (i) The medical record contains a thorough and accurate summary of the communication including all relevant aspects of the communication,
    - (ii) Original documentation of the communication is maintained outside of the medical record and is accessible by employees and contractors of the PACE organization when necessary, and in accordance with [§ 460.200(e)](/cfr/42/460.200.md?p=e), and
    - (iii) **Original documentation of the communication is available to CMS and the SAA upon request.**
  - (7) **Laboratory, radiological and other test reports.**
  - (8) **Medication records.**
  - (9) **Hospital discharge summaries, if applicable.**
  - (10) **Reports of contact with informal support (for example, caregiver, legal guardian, or next of kin).**
  - (11) **Enrollment Agreement.**
  - (12) **Physician orders.**
  - (13) **Discharge summary and disenrollment justification, if applicable.**
  - (14) **Advance directives, if applicable.**
  - (15) **A signed release permitting disclosure of personal information.**
- (c) **Transfer of medical records.** The organization must promptly transfer copies of medical record information between treatment facilities.
- (d) **Authentication of medical records.**
  - (1) All entries must be legible, clear, complete, and appropriately authenticated and dated.
  - (2) Authentication must include signatures or a secured computer entry by a unique identifier of the primary author who has reviewed and approved the entry.

## Notes

### Amendments

[64 FR 66279, Nov. 24, 1999, as amended at 71 FR 71337, Dec. 8, 2006; 86 FR 6135, Jan. 19, 2021; 88 FR 22345, Apr. 12, 2023 ]

### Authority

Authority: 42 U.S.C. 1302, 1395, 1395eee(f), and 1396u-4(f).

### Source

Source: 64 FR 66279, Nov. 24, 1999, unless otherwise noted.

### Amendments

[64 FR 66279, Nov. 24, 1999, as amended at 71 FR 71337, Dec. 8, 2006; 86 FR 6135, Jan. 19, 2021; 88 FR 22345, Apr. 12, 2023 ]