The Ultimate Medical Record Checklist for Medicare CoP Audits (42 CFR § 482.24)

When it comes to Medicare Conditions of Participation (CoPs), medical records are one of the most scrutinized areas during CMS audits. Under 42 CFR § 482.24, hospitals and small practices must maintain medical records that are accurate, complete, accessible, and systematically organized. These records serve as the primary evidence of care delivery, patient rights protection, and compliance with federal and state regulations.

For small practices, the challenge is often resource constraints. Without a compliance department or extensive staff, the responsibility of maintaining compliant medical records usually falls on a small team or even one administrator. Yet, CMS holds small practices to the same standards as larger facilities. Failure to comply can lead to deficiency citations, repayment demands, financial penalties, or loss of Medicare certification.

Understanding Medical Record Requirements Under 42 CFR § 482.24

CMS requires that medical records:

1. Be accurately written, promptly completed, properly filed, and retained (42 CFR § 482.24(b)).

2. Contain sufficient information to identify the patient, justify the diagnosis and treatment, and document results (42 CFR § 482.24(c)).

3. Be accessible to authorized staff for continuity of care.

4. Protect confidentiality from unauthorized use or disclosure.

5. Include authentication (signatures, dates, and approvals from authorized staff).

Records must provide a complete and accurate picture of the entire scope of patient care, covering every stage from admission through discharge. They should not only document treatments and services, but also demonstrate ongoing compliance with patient rights, clinical standards, and regulatory requirements, ensuring transparency, accountability, and continuity of care.

Why Medical Record Compliance Matters

• Clinical Accuracy: Ensures continuity of care and reduces medical errors.

• Audit Readiness: Medical records are the first documents CMS surveyors request.

• Legal Protection: Proper records defend practices in malpractice or liability claims.

• Reimbursement: Claims must be supported by accurate documentation.

• Reputation: Strong records improve trust with patients and regulatory bodies.

Every medical record must clearly identify the patient. Audit failures often stem from missing or inconsistent demographic information.

Checklist Items:

• Full legal name.

• Date of birth.

• Sex/gender identity (as applicable to care).

• Address and contact details.

• Insurance and billing information.

• Emergency contact.

• Patient identification number or medical record number.

Medical history is essential to justify treatment and demonstrate care planning.

Checklist Items:

• Chief complaint at admission/visit.

• History of present illness.

• Past medical and surgical history.

• Allergies and current medications.

• Family and social history (smoking, alcohol use, support systems).

• Physical examination findings.

CMS expects medical records to demonstrate ongoing, coordinated care.

Checklist Items:

• Physician orders, dated and signed (42 CFR § 482.24(c)(2)).

• Progress notes reflecting clinical reasoning.

• Nursing notes or allied health documentation.

• Consultations and referrals.

• Medication administration records.

• Diagnostic test results (labs, imaging).

• Evidence of informed consent for procedures.

42 CFR § 482.24 is closely tied to the protections outlined in § 482.13, making clear that medical records are not simply clinical documents but also tools to uphold patient rights. Records must go beyond charting diagnoses and treatments; they must demonstrate that patients were informed of their rights upon admission, provided with opportunities to ask questions, and involved in decisions about their care. Proper documentation shows surveyors that the facility not only delivered medical services but also respected autonomy, transparency, and informed consent, ensuring compliance with both the Conditions of Participation and ethical standards of care.

Checklist Items:

• Written notice of patient rights at admission.

• Documentation of grievance filings and resolutions.

• Records of advance directives.

• Consent for treatment and disclosure of information.

• Documentation of interpreter services when applicable.

Surveyors pay close attention to discharge documentation to ensure continuity of care.

Checklist Items:

• Discharge summary (diagnosis, treatment provided, results).

• Medication reconciliation at discharge.

• Instructions given to patient/family (follow-up appointments, care instructions).

• Referrals to post-acute or specialty care.

• Patient acknowledgment of receipt of discharge instructions.

Small practices can use EHR systems to close documentation gaps:

• Automated Prompts: Remind providers to sign orders.

• Template Use: Ensure required fields are completed.

• Audit Trails: Track who accessed or modified records.

• Encryption: Protect patient confidentiality in digital systems.

• Perform quarterly record reviews to identify documentation gaps.

• Use mock CMS audits to prepare staff for surveyor questions.

• Involve compliance officers or external consultants for unbiased evaluations.

Hospitals that use certified electronic health record (EHR) systems must meet an additional Medicare CoP requirement under 42 CFR § 482.24(d). Your EHR must be able to send real-time electronic notifications of patient status changes, specifically:

• Admissions

• Discharges

• Transfers

These alerts must be sent to the patient’s established care providers (primary care physicians, post-acute providers, or other practitioners responsible for care).

A small orthopedic clinic was cited during a CMS audit after surveyors identified multiple patient records missing signed physician orders for diagnostic imaging. While the imaging studies themselves were performed appropriately and medically justified, the absence of physician signatures created the appearance of noncompliance with Medicare’s documentation and order requirements. Regulators stressed that even when care is clinically sound, incomplete or missing signatures undermine accountability and open the door to potential misuse or billing irregularities.

Consequences

• CMS required the clinic to submit a corrective action plan addressing the documentation gap.

• All staff underwent retraining on documentation protocols, with an emphasis on ensuring that orders are signed, dated, and placed in the patient record prior to services being rendered.

• The clinic implemented electronic health record (EHR) safeguards, including prompts that prevent imaging orders from being processed until a physician’s electronic signature is captured.

Lesson Learned

This case highlights that proper documentation is just as important as proper care. Missing signatures, even without intent, can create compliance risks, attract regulatory scrutiny, and result in costly remediation.

This illustrates how minor documentation gaps can escalate into compliance risks.

Common Pitfalls in Medical Record Compliance

1. Incomplete Records

• Missing progress notes or unsigned orders.

2. Delayed Documentation

• Entries not made in real time.

3. Poor Legibility in Paper Records

• Handwritten notes that are unclear or unreadable.

4. Failure to Authenticate

• Records lacking provider signatures or electronic authentication.

5. Privacy Violations

• Leaving records unsecured or discussing them in public areas.

Compliance with § 482.24 requires more than checklists, it requires a documentation culture where staff see accurate records as integral to patient care.

• Reinforce that “if it isn’t documented, it didn’t happen.”

• Celebrate staff compliance successes.

• Provide feedback and retraining when gaps are found.

• Assign accountability: each role should know its documentation responsibilities.

Under 42 CFR § 482.24, medical record compliance is a central requirement of Medicare CoPs. For small practices, records must not only document treatment but also prove compliance with patient rights, safety, and continuity of care.

By following this ultimate checklist, covering identification, history, orders, patient rights, progress notes, and discharge documentation, small practices can prepare for CMS audits with confidence. The key is to embed compliance into daily workflow, ensuring records are accurate, complete, timely, and secure.

With strong documentation practices, small practices can avoid deficiencies, protect patient safety, and maintain Medicare certification, while building trust with the patients they serve

To further strengthen your compliance posture, consider using a compliance regulatory tool. These platforms help track and manage requirements, provide ongoing risk assessments, and keep you audit-ready by identifying vulnerabilities before they become liabilities, demonstrating a proactive approach to regulators, payers, and patients alike.

1. 42 CFR § 482.24 – Condition of Participation: Medical Record Services. Legal Information Institute

2. Office of Inspector General (OIG) – Compliance Program Guidance for Individual and Small Group Practices

3. Sample Checklists for Preparing and Responding to Audits of Electronic Health Records