Medical Record CoPs: [Surveyor Checklist] (42 CFR § 482.24)

Medicare’s Conditions of Participation (CoPs) establish mandatory requirements that providers must meet to participate in the Medicare program. Under 42 CFR § 482.24, medical record services must ensure that patient records are accurate, complete, authenticated, secure, and readily retrievable. During surveys, CMS surveyors evaluate whether small practices and facilities maintain medical records in compliance with these standards.

Failure to meet § 482.24 requirements can result in deficiencies, corrective action plans, payment consequences, or loss of Medicare participation. This article explains what surveyors evaluate during record reviews, clarifies regulatory requirements, provides a step-by-step compliance framework, includes a case study, and offers practical self-audit tools to help small practices maintain continuous readiness.

Introduction

Medical records are the foundation of patient care, reimbursement, and regulatory compliance. CMS surveyors rely heavily on record reviews to assess whether providers meet Medicare’s Conditions of Participation. For small practices, record-keeping deficiencies are among the most common, and avoidable, survey findings.

Under 42 CFR § 482.24, medical records must support the diagnosis, justify treatment, document patient progress, and demonstrate compliance with federal standards for authentication, confidentiality, and retention. Even when patient care is appropriate, documentation gaps can lead to serious compliance consequences.

Understanding exactly what surveyors look for allows small practices to proactively align their record-keeping practices with regulatory expectations.

42 CFR § 482.24 – Condition of Participation: Medical Record Services

42 CFR § 482.24 requires that providers maintain a medical record for every patient evaluated or treated and establishes standards across four core areas:

• Organization and Staffing (§ 482.24(a))
   Medical record services must be appropriately staffed to ensure prompt completion, filing, and retrieval of records.

• Form, Retention, and Confidentiality (§ 482.24(b))
   Records must be accurately written, promptly completed, properly filed, retained for required timeframes, and protected from unauthorized access.

• Content of Record (§ 482.24(c))
   Records must contain sufficient information to justify care, document patient progress, and support diagnoses and treatment.

• Electronic Notifications (§ 482.24(d))
   When applicable, electronic systems must support required notifications and information exchange in compliance with federal standards.

These requirements apply regardless of practice size.

CMS surveyors typically assess medical records across five core dimensions:

1. Accuracy and Completeness

Surveyors verify that records include:

• Medical history and physical examination

• Admitting or encounter diagnoses

• Orders, progress notes, and treatment documentation

• Test results, consults, and follow-up plans

Incomplete or inconsistent documentation may result in deficiencies under § 482.24(c).

2. Timeliness

Records must be promptly completed, with final documentation completed within 30 days following discharge or patient encounter, as applicable under § 482.24(c)(2).

Late entries without justification are frequently cited during surveys.

3. Authentication

All entries must be:

• Dated

• Timed

• Authenticated (signed electronically or in writing)

Missing signatures or undated notes violate § 482.24(c)(1) and are among the most common survey findings.

4. Confidentiality and Security

Surveyors assess whether practices:

• Restrict access to authorized users only

• Protect records from loss, destruction, or unauthorized access

• Secure both paper and electronic records

Failures in this area violate § 482.24(b) and may also raise HIPAA concerns.

5. Retrievability

Records must be:

• Organized

• Indexed or searchable

• Readily retrievable for patient care or surveyor review

Inability to produce requested records promptly may indicate noncompliance with § 482.24(c)(4).

Step 1: Establish Written Medical Record Policies

• Define documentation standards

• Address record completion timelines

• Include confidentiality and retention requirements
   (§ 482.24(b))

Step 2: Standardize Documentation

• Use consistent templates for notes and summaries

• Require authentication on all entries
   (§ 482.24(c)(1))

Step 3: Monitor Record Completion Timelines

• Track open charts

• Enforce 30-day completion requirements
   (§ 482.24(c)(2))

Step 4: Secure Records

• Lock paper files

• Use role-based access controls for EHRs
   (§ 482.24(b))

Step 5: Test Record Retrieval

• Periodically request sample charts

• Verify rapid retrieval capability
   (§ 482.24(c)(4))

Step 6: Train Staff

• Train providers and staff annually on record requirements

• Document training attendance

Case Study: Survey Deficiency Due to Documentation Gaps

A small internal medicine practice underwent a CMS survey. Reviewers found that approximately 20% of records lacked provider authentication and several discharge summaries were completed beyond the 30-day timeframe.

Outcome

• Deficiencies cited under 42 CFR § 482.24(c)(1) and § 482.24(c)(2)

• Corrective action plan required

• Delayed Medicare payments during remediation

Key Lesson

Care delivery alone is insufficient. Documentation must independently meet regulatory standards.

Common Pitfalls to Avoid

• Incomplete or late documentation

• Missing signatures or dates

• Unsecured paper charts

• Disorganized electronic files

• Lack of written policies

Each of these may result in survey deficiencies even when patient care is appropriate.

• Use EHR alerts for unsigned or incomplete notes

• Assign oversight responsibility for records

• Conduct periodic internal audits

• Centralize record policies and logs

• Align HIPAA safeguards with CoPs requirements

Sustainable compliance requires leadership involvement, staff accountability, and routine review. When documentation standards are reinforced consistently, practices remain survey-ready and reduce regulatory risk.

Under 42 CFR § 482.24, CMS surveyors evaluate whether medical records are accurate, complete, authenticated, secure, and retrievable. Small practices that align their documentation processes with these standards are better positioned to maintain Medicare participation, avoid deficiencies, and protect patient trust.

Proactive policies, consistent monitoring, and staff training are essential to sustaining compliance and minimizing survey risk.

Compliance should be a living process. By leveraging a regulatory tool, your practice can maintain real-time oversight of requirements, identify vulnerabilities before they escalate, and demonstrate to both patients and payers that compliance is built into your culture.

• 42 CFR § 482.24 Medical Record Services
  

• State Operations Manual, Appendix A
  

• HIPAA for Professionals
  

• Compliance Guidance for Physicians
  

• Medicare and Medicaid Programs; Hospital Conditions of Participation