Are There Gaps in Your Meeting Minutes?

By Cyndi Newman, MSHL, BSN, RN, Senior Clinical Review Specialist 

Cyndi Newman is an ACHC Senior Clinical Review Specialist for office-based surgery and ambulatory surgery centers. She has over 30 years of experience as a registered nurse, surveyor, and risk manager. Cyndi is passionate about quality patient care and the collaborative nature of accreditation. 

Posted: September 4, 2026

Governing body meeting minutes serve as a legal and regulatory safeguard for ambulatory surgery centers (ASCs). As organizations navigate an increasingly complex regulatory and clinical environment, ASC governing bodies must ensure that their decisions, discussions, and oversight activities are fully documented.

Ambulatory surgery centers are subject to oversight from federal regulators, state agencies, and accreditation organizations. During an ACHC ASC Accreditation survey, the organization’s planning, implementation, and accountability for services to patients will be assessed. The governing body meeting minutes will be one of the first things a surveyor requests to review.

ACHC Standard 01.01.02 Governing Body Responsibilities requires that the governing body establish bylaws or similar documents, such as policies, defining its responsibilities for maintaining meeting minutes that reflect attendance and deliberations leading to actions.

Keep minutes clear

Surveyors review governing body meeting minutes to ensure that leadership is actively engaged in the oversight of patient safety, quality assurance, infection control, and credentialing.

The meeting minutes should document that the governing body is fulfilling its role, making informed decisions, and addressing identified concerns and risks. Incomplete or vague meeting minutes fail to show that the organization’s compliance and governance are effective. This could lead to future disputes among governing body members, duplication of efforts, and regulatory fallout.

Meeting minutes should be clear, concise, and structured. They should include attendance, key discussion points, decisions made, and assigned action items. Consistency in format and timely completion are also important to ensure reliability and usability.

At a minimum, meeting minutes should include the following:

  • Meeting date and time.
  • Attendance and absences.
  • Items discussed.
  • Actions taken.
  • Follow-ups needed and who is responsible.
  • Goals achieved.
  • Signatures of governing body members or chair.
  • Date of the next scheduled meeting.

Continuity matters

Governing body membership may change over time. Detailed meeting minutes will help new members understand past decisions and identify items needing further attention.

Some recent observations made by ACHC Surveyors include:

  • The minutes are vague and include too little information. Example: “QAPI plan reviewed.”
  • The minutes are not legible.
  • Minutes lack the name of the individual(s) responsible for follow-up and an expected time to complete actions.
  • Documentation that the follow-up was completed is missing.
  • The minutes were not available when requested by the surveyor.

Your meeting minutes document a moment in time for future recall. Ensure they show the deliberations and decisions made by your governing body to keep you better prepared for regulatory inquiries and surveys.

Best meeting practices

The following are tips for structuring governing body meetings to support compliance:

  • Set aside time for meeting preparation.
  • Be consistent with meeting frequency.
  • Allow enough time to cover all agenda items.
  • Send clear communication on meeting dates and time.
  • Be factual and focus on outcomes and decisions.
  • Write the minutes during or soon after the meeting while memory is fresh.
  • Make sure all tasks and assignments are followed up and recorded at the next meeting.
  • Ensure minutes are accessible when needed and by more than one individual.

Key takeaways

Accurate and detailed governing body meeting minutes are a foundational element of strong and effective governance in an ASC. Complete and accurate meeting minutes are not merely administrative records—they are essential tools that support compliance, accountability, and quality improvement.

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