42 C.F.R. § 456.170 – Medical, psychiatric, and social evaluations.

(a) Before admission to a mental hospital or before authorization for payment, the attending physician or staff physician must make a medical evaluation of each applicant's or beneficiary's need for care in the hospital; and appropriate professional personnel must make a psychiatric and social evaluation.
(b) Each medical evaluation must include—
1. (1) Diagnoses;
2. (2) Summary of present medical findings;
3. (3) Medical history;
4. (4) Mental and physical functional capacity;
5. (5) Prognoses; and
6. (6) A recommendation by a physician concerning—
  1. (i) Admission to the mental hospital; or
  2. (ii) Continued care in the mental hospital for individuals who apply for Medicaid while in the mental hospital.