Transcription of Principles of Documentation - CMS
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Principles of Documentation - CMS
Principles of Documentation October 2018 Principles OF Documentation - 2017 FOR THE STATEMENT OF DEFICIENCIES ( form CMS-2567) Table of Contents Introduction 2 Definitions 3 Legal Aspects of the Statement of Deficiencies 5 Principles of Documentation /Overview 7 Principle # 1: laboratory Compliance and Noncompliance 10 Principle # 2: Using Plain Language 12 Principle # 3: Composition of a Deficiency Citation 13 Regulatory Reference 13 Statement of Deficient Practice 15 Extent 16 Identifiers 19 Sources of the Evidence 20 Outcomes 28 Findings 29 Facts 30 Organization of the Findings 32 Principle #4: Relevance of Onsite Correction of Findings 37 Principle #5: Interpretive Guidelines 40 Principle #6: Citation of State or Local Code Violations 42 Principle #7: Cross References 44 Principle #8: Condition Deficiencies 46 Proofreading 48 Conclusion 49 Appendices Appendix A: Composing a Deficiency Tag (D-Tag) Appendix B: Checklist, Composing D-Tags Appendix
The Form CMS-2567 is the record of the survey where the surveyor(s) documents and justifies the determination of compliance and informs the laboratory of its state of compliance for CLIA certification. This information will serve as the basis for the laboratory to analyze its deficient practices or system failures and to develop plans of ...
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