42 CFR § 456.180 - Individual written plan of care.

---
identifier: "/us/cfr/t42/s456.180"
source: "ecfr"
legal_status: "authoritative_unofficial"
title: "42 CFR § 456.180 - Individual written plan of care."
title_number: 42
title_name: "Public Health"
section_number: "456.180"
section_name: "Individual written plan of care."
chapter_name: "CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES"
subchapter_number: "C"
subchapter_name: "MEDICAL ASSISTANCE PROGRAMS"
part_number: "456"
part_name: "UTILIZATION CONTROL"
positive_law: false
currency: "2026-03-24"
last_updated: "2026-03-24"
format_version: "1.1.0"
generator: "[email protected]"
authority: "42 U.S.C. 1302."
regulatory_source: "43 FR 45266, Sept. 29, 1978, unless otherwise noted."
cfr_part: "456"
---


# 456.180 Individual written plan of care.

(a) Before admission to a mental hospital or before authorization for payment, the attending physician or staff physician must establish a written plan of care for each applicant or beneficiary.

(b) The plan of care must include—

(1) Diagnoses, symptoms, complaints, and complications indicating the need for admission;

(2) A description of the functional level of the individual;

(3) Objectives;

(4) Any orders for—

(i) Medications;

(ii) Treatments;

(iii) Restorative and rehabilitative services;

(iv) Activities;

(v) Therapies;

(vi) Social services;

(vii) Diet; and

(viii) Special procedures recommended for the health and safety of the patient;

(5) Plans for continuing care, including review and modification to the plan of care; and

(6) Plans for discharge.

(c) The attending or staff physician and other personnel involved in the beneficiary's care must review each plan of care at least every 90 days.