42 CFR §456.170

1. (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.
2. (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.