{"ref":"CA-HSP-REC-01","title":"Medical Record Service, Content and Authentication","category":"Records","summary":"Sets up the Agency's medical record service: one complete, accurate and organized record for every patient, open to authorized individuals 24 hours a day; the information governance policies the governing body approves; the eight record activities California requires (retrieval, reconciliation, deficiency analysis, coding, filing, indexing, quality and content control, release of information); everything the record must contain under 22 CCR §74892; and how entries are authenticated.","inShort":["Write your visit note on the day of the visit, under your own login. Never use anyone else's login or share yours.","Every entry needs the date, the time of the visit, what you did and your electronic signature.","Put the patient's allergies where everyone can see them, and update them as soon as you learn of a new one.","If the records lead sends you a missing-item notice, fix it by the end of the next business day.","Records can be reached 24 hours a day. If a CDPH surveyor asks to see a record, tell the Administrator at once."],"primaryCitation":"22 CCR §74888","citations":["22 CCR §74888","22 CCR §74892","22 CCR §74896(a), (d)-(f), (l)","22 CCR §74800(a)(2), (8), (9), (39)","22 CCR §74808(e)-(f)","22 CCR §74880(d)(4)(E)","22 CCR §74908(b)(7)"],"federalCitations":["42 CFR §418.104","42 CFR §418.54(e)"],"surveyorAsks":["Show me how your medical record system is organized and how authorized staff reach a record at 2 a.m.","Walk me through your reconciliation and deficiency analysis when a patient is discharged or dies."],"forms":[{"ref":"CA-HSP-REC-01-A","title":"Medical Record Audit and Deficiency Analysis Tool"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (22 CCR §74888; 42 CFR §418.104)","5. Information Governance (22 CCR §74888(b))","6. The Eight Record Activities (22 CCR §74888(c))","7. Access 24 Hours a Day (22 CCR §74888(d)-(e); §74808(e)-(f))","8. What Every Record Contains (22 CCR §74892)","9. How the Record Is Organized (Indexing)","10. Making Entries (22 CCR §74896(d)-(f); 42 CFR §418.104(b))","11. Records of Care Given Away From the Home","12. Responsibilities","13. Records and Compliance Monitoring","14. Staff Training","15. References","16. Related Policies and Forms","17. Approval","18. Revision History"],"version":"1.0","sample":false,"pack":"ca-hospice","state":"California","service":"Hospice","guides":[{"path":"/guides/hospice-policies/","h1":"What policies are required for hospice?"},{"path":"/guides/hospice-conditions-of-participation/","h1":"Hospice Conditions of Participation: which policies each one needs"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}