{"ref":"LA-HH-REC-01","title":"Clinical Records: Content, Clinical Notes, Authentication, and Retention","category":"Records","summary":"Sets out what every clinical record must contain under LAC 48:I §9129.C, how each visit is documented in a clinical note that is incorporated into the record within one week of the visit, how entries are authenticated, dated and timed, where original records are kept at the parent and branch offices, how records are protected and corrected, and how long they are retained: not less than six years from the date the record was established (§9129.A.8) and, if the Agency is Medicare-certified, at least five years after discharge (42 CFR §484.110(c)), whichever is later.","inShort":["Write a clinical note for every visit: date, arrival and exit times, what you did, vital signs, comments and your signature.","Submit your note by the end of the next business day. It must be in the record within one week of the visit.","Have the patient or a responsible person sign the record of visit.","Never sign, write or change a note for someone else, and never share your login.","Correct errors with an addendum or a single line through. Never erase or delete.","Records are kept at least six years, and longer if needed. Report a lost record or device at once."],"primaryCitation":"LAC 48:I §9129","citations":["LAC 48:I §9129","LAC 48:I §9129.A","LAC 48:I §9129.B","LAC 48:I §9129.C","LAC 48:I §9118.E.3","LAC 48:I §9103.C.2.e","LAC 48:I §9103.K.2.h","LAC 48:I §9127.A.1.f","LAC 48:I §9110.F","R.S. 40:2116.31(B)(2)","R.S. 40:1163.1","R.S. 51:3074"],"federalCitations":["42 CFR §484.110","42 CFR §484.110(a)","42 CFR §484.110(b)","42 CFR §484.110(c)","42 CFR §484.110(d)","42 CFR §484.110(e)","45 CFR §164.530(j)"],"surveyorAsks":["Show me this patient's clinical record. Where are the plan of care signed by the authorized healthcare provider, the current comprehensive assessment and the clinical notes for the past 60 days?","How do you make sure every clinical note is in the record within one week of the visit?"],"forms":[],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (LAC 48:I §9129)","5. One Record for Each Patient, and Where It Is Kept","6. Contents of the Active Clinical Record","7. Clinical Notes and the Record of Visit","8. Writing and Authenticating Entries","9. Corrections, Late Entries, and Addenda","10. Protecting the Record","11. Retention, Legal Holds, and Destruction","12. Record Completion Monitoring","13. Responsibilities","14. Records and Compliance Monitoring","15. Staff Training","16. References","17. Related Policies and Forms","18. Approval","19. Revision History"],"version":"1.0","sample":false,"pack":"la-hha","state":"Louisiana","service":"Home health","guides":[{"path":"/guides/home-health-agency-policies/","h1":"What policies and procedures are required for home health agencies?"},{"path":"/guides/home-health-conditions-of-participation/","h1":"Home health Conditions of Participation: which policies each one needs"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}