F0842 — Medical Records
F0842 requires the facility to maintain accurate, complete, and accessible medical records for each resident, retained for the required period and safeguarded against loss, destruction, or unauthorized use.
Common Deficiency Examples
- Missing or incomplete documentation for care provided
- Record inconsistencies between different sections (e.g., care plan vs. nursing notes)
- Records not retrievable within a reasonable timeframe
- Retention or safeguarding requirements not met
What Your Plan of Correction Needs
F0842 PoCs should distinguish between a documentation completeness gap and a records-management/access gap:
Frequently Asked Questions
How is F0842 different from F0845?+
F0842 is the broader recordkeeping requirement — accuracy, completeness, accessibility, and safeguarding of medical records. F0845 covers a more specific checklist of required content elements (identification data, assessments, physician orders, discharge summary, etc.). A missing chart section falls under F0845; a records-access or retention problem falls under F0842.
Related tags in Administration
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