{"ref":"TX-HH-REC-01","title":"Clinical Records: Content, Authentication, Access, and Retention","category":"Records","summary":"Sets out how the Agency builds and keeps a complete clinical record for every patient: what goes in it, how entries are written, signed, dated, timed, and corrected, how fast visit notes reach the record, where originals are stored, who may see or take a record, how patients get a free copy, and how long records are kept.","inShort":["Write your visit note the same day you see the patient, and sign it with your name, title, date, and time.","Fix a paper mistake with one line through it, the date, and your initials. Never use correction fluid or tear out a page.","Get your notes to the office quickly. They must be in the record within 14 working days.","Do not take a record out of the office without the supervising nurse’s approval.","If a patient asks for their record, tell the office the same day. They get a free copy fast."],"primaryCitation":"26 TAC §558.301","citations":["26 TAC §558.301","26 TAC §558.282(f)(7)","26 TAC §558.288","26 TAC §558.295","26 TAC §558.256(n)","26 TAC §558.507","Tex. Health & Safety Code §181.102","Tex. Hum. Res. Code ch. 102"],"federalCitations":["42 CFR §484.110","42 CFR §484.60(a)(3)","42 CFR §484.50(c)(6)","42 CFR §484.40","45 CFR §164.524","45 CFR §164.530(c)"],"surveyorAsks":["Show me the clinical note for this visit. When was it written, and when was it incorporated into the record?","How does a nurse correct a mistake in the paper record, and how does your electronic system show a change?"],"forms":[{"ref":"TX-HH-REC-01-A","title":"Authorization to Release Health Information"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (26 TAC §558.301)","5. Contents of the Clinical Record","6. Writing, Signing, and Correcting Entries","7. Storage, Use, and Removal of Records","8. Patient Access to the Record","9. Release to Others, Retention, and Destruction","10. Responsibilities","11. Records and Compliance Monitoring","12. Staff Training","13. References","14. Related Policies and Forms","15. Approval","16. Revision History"],"version":"1.0","sample":false,"pack":"tx-lhhs","state":"Texas","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 Home Health Agency","legalName":"Sample Home Health Agency, LLC","logo":null}}