{"ref":"DC-HC-REC-01","title":"Client Records and Service Delivery Notes","category":"Records","summary":"Sets out what every client record must contain under 22-B DCMR §9914.2, how home health aides write service delivery notes, the Agency's documentation standards for late entries, corrections and electronic signatures, where records are kept and how fast they are produced for DC Health, and how clients see their own records.","inShort":["Write a service delivery note for every visit before you leave the home. Never write a note ahead of time.","Record each task as done, not done or refused, and say why and whom you told when a task was not done.","Write down any change in the client, any fall or injury, and anything that worries you, with the name of the nurse you told.","Sign and date every entry. Never sign for someone else or let anyone use your login.","To fix a mistake on paper, draw one line through it, write \"error\", your initials and the date. Never use correction fluid.","Clients may see their own record. Pass any request to the office the same day."],"primaryCitation":"22-B DCMR §9914","citations":["22-B DCMR §9914.1","22-B DCMR §9914.2","22-B DCMR §9901.4(a)","22-B DCMR §9901.5","22-B DCMR §9915.4","22-B DCMR §9915.7","22-B DCMR §9916.2(l)","22-B DCMR §9916.6","22-B DCMR §9918.2","22-B DCMR §9999.1"],"federalCitations":["45 CFR §164.524 (only if the Agency is a HIPAA covered entity)"],"surveyorAsks":["Show me this client's record. Where are the signed service agreement, the initial RN assessment and the current service plan?","Where are the aide's service delivery notes for last week, and who signed them?"],"forms":[{"ref":"DC-HC-REC-01-A","title":"Client Record Audit Checklist"},{"ref":"DC-HC-REC-01-B","title":"Service Delivery Note"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (22-B DCMR §9914)","5. What Every Client Record Contains","6. How the Record Is Organized","7. Service Delivery Notes","8. When Notes Are Written and Turned In","9. Documentation Standards","10. Electronic Records","11. Where Records Are Kept and DC Health Access","12. Documents Kept in the Client's Home","13. Client Access to the Record","14. Record Audits","15. Responsibilities","16. Records and Compliance Monitoring","17. Staff Training","18. References","19. Related Policies and Forms","20. Approval","21. Revision History"],"version":"1.0","sample":false,"pack":"dc-hca","state":"Washington, DC","service":"Home care","guides":[{"path":"/guides/home-care-agency-policies/","h1":"What policies does a home care agency need?"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}