@1100 words, 7 pages including cover sheet and sources. Written for HIT220, January, 2012

1. Running head: The Role of the Centers for Medicare and Medicaid Services in Setting Standards for Clinical Records 1
The Role of the Centers for Medicare and Medicaid Services
in Setting Standards for Clinical Records
Mary Strube
January 22, 2012
Professor Theodos
HIT 220
DeVry University Online

2. The Role of the Centers for Medicare and Medicaid Services in Setting Standards for Clinical Records 2
Table of Contents
Introduction ..................................................................................................................................... 3
Overview of CMS Standards .......................................................................................................... 3
Standards of Clinical Record Content, Protection, and Retention and Preservation ...................... 4
CMS Plays a Role in Setting Standards .......................................................................................... 5
Conclusion ...................................................................................................................................... 6

3. The Role of the Centers for Medicare and Medicaid Services in Setting Standards for Clinical Records 3
Introduction
The scope of this paper is to demonstrate the role of the Centers for Medicare and
Medicaid Services (CMS) in setting standards regarding clinical health records. Although CMS
is responsible for dozens of regulations regarding the clinical record, this paper will highlight
only a few in an attempt to show the relevance of the agency in setting standards of clinical
record content, maintenance, and retention and preservation. This paper is not designed to be a
comprehensive listing of the regulations mandated by CMS, but merely to demonstrate the
importance of the agency as a standards-setting body.
Overview of CMS Standards
CMS is the branch of the United States Department of Health and Human Services that
administers Medicare and the federal portion of the Medicaid programs. Because CMS is a
federal body, regulations issued by them must be followed in every state. Due to its standing as
a representative of the federal government, accrediting bodies, such as the Joint Commission,
often refer to CMS guidelines when creating their own standards for accreditation. (Johns & al.,
2011)
Data taken from health records of Medicare patients are used by CMS to make decisions
regarding such things as reimbursement, the effectiveness of healthcare services, and the general
overall health of patients who are covered by the CMS programs. These decisions are examined,
and recommendations are made that, if followed, will result in an increase in the quality of
patient care. These recommendations are collectively known as standards of quality, or

4. The Role of the Centers for Medicare and Medicaid Services in Setting Standards for Clinical Records 4
standards of care, and are a written description of features that are expected as a minimum level
of service to be provided in a healthcare environment. (Johns & al., 2011)
CMS has taken their standards and compiled them into a list of requirements called
Conditions of Participation (CoP). In order for a provider to receive reimbursement through the
Medicare program, he must meet or exceed the requirements listed in the CMS CoP. Because
the Joint Commission uses CMS guidelines as a basis for its accrediting process, any facility that
is accredited by the Joint Commission is considered by CMS to be in compliance with the CoP.
(Johns & al., 2011)
CMS has developed CoP standards to address all areas of a healthcare organization,
including standards for the clinical record. CoP regulations regarding the clinical record can be
found in the US statutes, Title 42, Volume 3, Chapter IV, Part 485. CMS regulations state that a
facility is required to maintain a clinical record for each patient and that the record must be
documented, accessible and organized to allow for ease of retrieval. Three standards are
specified in the statute: content, protection of information, and retention and preservation. (U.S.
Government Printing Office, 2005)
Standards of Clinical Record Content, Protection, and Retention and Preservation
The content standard specifies what items are to be contained in the clinical record. The
content standard states that a clinical record must contain enough information so that the patient
is clearly identified and to show that diagnoses and treatments are justified. Entries must be
timely. Entries must be signed by the person providing care, and if this person is an "assistant
level personnel," then the record must be countersigned by a supervisor. Specific documentation

5. The Role of the Centers for Medicare and Medicaid Services in Setting Standards for Clinical Records 5
requirements include initial assessment, plan of treatment, consent forms, medical history,
physical exams, progress notes, and a discharge summary. (U.S. Government Printing Office,
2005)
There is a standard defining how data is to be maintained in the clinical record, referred
to by CMS as protection. The standard of protection of clinical record content states that a
facility must protect the record against unauthorized use, loss and destruction. Location-specific
policies and procedures for the use, removal, and release of information must be in place inside
the facility. Any information that is protected must have the patient's written consent before it
can be released to a third party. (U.S. Government Printing Office, 2005)
Finally there are standards for the retention and preservation of clinical records. This
standard states that the facility must retain the clinical record for a period of 5 years following
discharge of the patient. If the facility is no longer able to treat patients, it is required to make
provisions for the maintenance of the clinical records of its former patients. (U.S. Government
Printing Office, 2005)
CMS Plays a Role in Setting Standards
CMS plays a role in setting standards throughout the healthcare industry. Theirs are not
the only standards that are followed. Although CMS has printed rules regarding the clinical
record, actual standards vary between federal and state regulations, accrediting-body guidelines,
and facility policies. It is important that all of these voices be heard rather than listening to only
one. (Johns & al., 2011)

6. The Role of the Centers for Medicare and Medicaid Services in Setting Standards for Clinical Records 6
One reason for this is because of ambiguity of the US statutes. For example, the
Medicare COP as stated above require a retention period for clinical records of 5 years, but the
federal government allows civil penalties to be imposed for a period longer than 5 years. This
has lead some states, such as Texas, to recommend retention periods longer than those
recommended by CMS. (Texas Medical Association, 2007)
It is common practice that the strictest standards available are the ones that are followed.
Facilities look at all available information when designing policies and procedures with regards
to the clinical record. Content, maintenance, and retention and preservation guidelines are
created and followed by a facility by keeping in mind all standards and rules from all accrediting
and regulatory agencies that are relevant to the facility and its records, not just those of CMS.
(Johns & al., 2011)
Conclusion
It is clear that CMS plays an important role in setting standards for quality healthcare
delivery in the United States. As a federal body, its recommendations serve as a basis for
regulations issued by states and accrediting organizations. Using standards and guidelines issued
by various governing and regulatory bodies, facilities create local policies and procedures
regarding the content, maintenance, and retention and preservation of the clinical record. Many
agencies work toward the common goal of increasing the quality of patient care. CMS plays an
important role in the process.

7. The Role of the Centers for Medicare and Medicaid Services in Setting Standards for Clinical Records 7
Works Cited
Johns, M. L., & al., e. (2011). Health Information Management Technology An Applied
Approach (Third ed.). Chicago: AHIMA Press.
Texas Medical Association. (2007, September). rightnow.texmed.org/ci/fattach/get/7361.
Retrieved January 2012, from rightnow.texmed.org:
http://rightnow.texmed.org/ci/fattach/get/7361/
U.S. Government Printing Office. (2005, October 1). Section. Retrieved January 2012,
from U.S. Government Printing Office:
http://edocket.access.gpo.gov/cfr_2005/octqtr/42cfr485.60.htm