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Administration42 CFR §483.70(i)
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:
Gap identifiedspecific record deficiency (missing entry, inconsistency, retrieval issue)
Immediate actioncorrection or completion of the specific record
Systemic fixdocumentation workflow, EHR configuration, or records management process
Monitoring planperiodic record completeness audits at a defined frequency
Related tags in Administration
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