{"ref":"NC-HSP-REC-01","title":"Medical Records: Content, Handling and Retention","category":"Records","summary":"Sets out what every hospice medical record contains, how entries are made, dated and authenticated, where originals and copies are kept, the five-working-day return and sign-out log for records removed for the annual evaluation, release of records, and a single retention rule that meets the North Carolina three-year and minor periods, the federal six-year period and the Medicare seven-year period for order and certification documentation.","inShort":["Chart every visit on the day you make it, with your own login and signature. Never sign or chart for someone else.","If you write about something that happened on an earlier day, label it \"Late entry\" and give both dates.","Correct mistakes with the EHR amendment tool or a single line on paper. Never erase or back-date.","Original records stay on the licensed premises. A record taken out for the annual evaluation goes on the sign-out log and comes back within five working days.","Leave only copies in the home folder: care plan, medication list, emergency plan and phone numbers.","Records are kept at least 7 years after death or discharge, longer for minors. Send release requests to the Privacy Official."],"primaryCitation":"10A NCAC 13K .0902","citations":["10A NCAC 13K .0301(a)(8)","10A NCAC 13K .0901","10A NCAC 13K .0902","10A NCAC 13K .0209(3)","10A NCAC 13K .0505(e)","G.S. 131E-207","NC Medicaid Clinical Coverage Policy 3D, sections 5.2.2.4, 7.1, 7.7"],"federalCitations":["42 CFR §418.104","42 CFR §424.516(f)","45 CFR §164.508","45 CFR §164.530(j)"],"surveyorAsks":["Show me a complete record for a current patient and for a patient who died last year. Where is the signed rights form and the consent for care?","How do you mark a late entry? Show me one."],"forms":[{"ref":"NC-HSP-REC-01-A","title":"Authorization to Release Health Information"},{"ref":"NC-HSP-REC-01-B","title":"Medical Record Sign-Out Log"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (10A NCAC 13K .0902)","5. What Every Record Contains","5.1 Federal content (if the Agency is Medicare-certified)","5.2 Other documents kept in the record","6. Making Entries","6.1 Late and out-of-sequence entries","6.2 Corrections","6.3 Electronic records and signatures","7. Originals, Copies and Where Records Are Kept","7.1 Notes from contracted providers and facilities","8. Records Removed for the Annual Evaluation","9. Department Access and the Statement Denying Access","10. Retention","10.1 Other retention rules that touch the record","11. Discharge, Transfer and Death","12. Releasing Records","13. Storage and Destruction","14. Records if the Agency Closes","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":"nc-hospice","state":"North Carolina","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}}