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Administration42 CFR §483.70(i)(5)
F0845 — Medical Record Content
F0845 specifies the required content elements of the medical record — including identification information, admission data, assessments, care plans, physician orders, progress notes, and discharge summary — distinct from F0842's broader recordkeeping requirement.
Common Deficiency Examples
- Required content element missing from a resident's record
- Progress notes not reflecting frequency required by resident condition
- Discharge summary incomplete or missing required components
- Physician orders not consistently documented or signed
What Your Plan of Correction Needs
F0845 PoCs should be specific about which content element was missing, since this tag covers a defined checklist:
Gap identifiedspecific missing content element
Immediate actionrecord completed retroactively where possible
Systemic fixrecord content checklist built into admission/ongoing documentation workflow
Monitoring planrecord content audits at a defined frequency
Related tags in Administration
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