{"ref":"LA-HSP-REC-01","title":"Clinical Records, Retention and Access","category":"Records","summary":"Sets out what every patient’s clinical record must contain, the time by which each discipline’s notes must be in the record under Chapter 82, how entries are signed and corrected, where records are kept and who may use them, how patients and families get access and copies within Louisiana and HIPAA time limits, how information is released, and how long records are kept and then destroyed.","inShort":["Keep a complete, accurate record for every patient. Sign each entry with your own log-in and never share a password.","Our rule: finish and sign each visit note by the end of the next business day. Louisiana’s outer limit is one week for nurses, social workers and therapists, and weekly for aides, LPNs and assistants.","Never erase or write over an entry. Correct it with an addendum, or on paper with one line, the word “error”, the date and your initials.","Records are kept for at least seven years after discharge or death (Louisiana requires six). Keep them locked and out of sight in the field.","Release information only with the patient’s signed authorization (Form LA-HSP-REC-01-A) or when a law requires it.","Send every request for copies, subpoena or police request to the Privacy Official the same day. Copies go out within 15 days of a complete request."],"primaryCitation":"LAC 48:I §8233","citations":["LAC 48:I §8233","LAC 48:I §8241.F","LAC 48:I §8217","LAC 48:I §8219.C.2","LAC 48:I §8221.B.1.b","LAC 48:I §8231.A.8","LAC 48:I §8237.D.7","LAC 48:I §8243.F","LAC 48:I §8205.E.6","LAC 48:I §8207.A.9","LAC 48:I §8207.A.11.c","LAC 48:I §8257.E.2","R.S. 40:1165.1","R.S. 40:1171.4","R.S. 51:3074(B)"],"federalCitations":["42 CFR §418.104","42 CFR §418.108(c)(3)","42 CFR §424.516(f)","45 CFR §164.508","45 CFR §164.510(b)","45 CFR §164.524","45 CFR §164.530(j)"],"surveyorAsks":["Show me this patient’s clinical record, including the certification, election statement, plan of care and the clinical notes for the past 60 days.","How do you make sure nurses, social workers and therapists put their notes in the record within one week of the visit?"],"forms":[{"ref":"LA-HSP-REC-01-A","title":"Authorization to Release Health Information"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (LAC 48:I §8233)","5. What the Clinical Record Contains","6. When Each Discipline Documents","7. Entries, Signatures and Corrections","8. Storage, Location and Safeguards","9. Who May Use the Record","10. Patient Access and Copies","10.1 Receiving a request","10.2 Time limits","10.3 Form of copies and charges","10.4 Records of a patient who has died","10.5 Denials and other rights","11. Releasing Information to Others","12. Transfer, Discharge and Records Sent to Others","13. Retention and Destruction","14. Responsibilities","15. Records and Compliance Monitoring","16. Staff Training","17. References","18. Related Policies and Forms","19. Approval","20. Revision History"],"version":"1.0","sample":false,"pack":"la-hospice","state":"Louisiana","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}}