Patient Health Records: Content, Timeliness, Storage, and Retention
Sets out what goes into every patient health record (22 CCR §74735(a)), how entries are made and authenticated, the time limits that apply (clinical notes signed and incorporated at least every seven working days; discharged records completed within 30 days), how records are kept available, safeguarded, and stored off site, how long they are kept (adults at least seven years after discharge; minors at least one year after age 18 and not less than seven years; Medi-Cal service records 10 years), the immediate written report to the Department when records are defaced or destroyed early, and how records are destroyed at the end of the retention period.
- Policy number
- CA-HH-REC-01
- Version
- 1.0
- Main rule
- 22 CCR §74735
- Library
- California home health · 58 policies
- Category
- Records
- Sections
- 25
In short
- Write your note at the time of the visit. Notes must be signed and in the record within seven working days; send yours by the end of the next working day.
- Write in permanent ink. Never use correction fluid. To fix a mistake, draw one line through it, write "error", the correction, the date, and your initials.
- Make sure allergies are easy to see on the face sheet and the medication profile.
- Never sign for someone else or let anyone use your login.
- Keep records with you out of sight and locked away. If a record or device is lost or stolen, tell your supervisor right away.
- Records of adults are kept at least seven years after discharge. Never throw a record in the trash.
What's inside
25 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (22 CCR §74735)
- 5. Opening the Record
- 6. What the Record Contains
- 7. Making Entries
- 8. Time Limits
- 9. Availability of Records
- 10. Safeguarding and Storage
- 10.1 In the office
- 10.2 In the field
- 10.3 Off-site storage
- 11. Retention
- 12. Records Defaced or Destroyed Early
- 13. Destruction at the End of Retention
- 14. Closure and Change of Ownership
- 15. Responsibilities
- 16. Records and Compliance Monitoring
- 17. Staff Training
- 18. References
- 19. Related Policies and Forms
- 20. Approval
- 21. Revision History
An inspector may ask
- Show me the health record for this patient. Where are the admission record, the plan of treatment, the allergies, the clinical notes, and the signed consent?
- How do you make sure clinical notes are signed and in the record at least every seven working days?
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