Skip to content

Medical Record Service, Content and Authentication

Sets up the Agency's medical record service: one complete, accurate and organized record for every patient, open to authorized individuals 24 hours a day; the information governance policies the governing body approves; the eight record activities California requires (retrieval, reconciliation, deficiency analysis, coding, filing, indexing, quality and content control, release of information); everything the record must contain under 22 CCR §74892; and how entries are authenticated.

Preview: full text with a package
About this policy
Policy number
CA-HSP-REC-01
Version
1.0
Main rule
22 CCR §74888
Library
California hospice · 60 policies
Category
Records
Sections
19

In short

  • Write your visit note on the day of the visit, under your own login. Never use anyone else's login or share yours.
  • Every entry needs the date, the time of the visit, what you did and your electronic signature.
  • Put the patient's allergies where everyone can see them, and update them as soon as you learn of a new one.
  • If the records lead sends you a missing-item notice, fix it by the end of the next business day.
  • Records can be reached 24 hours a day. If a CDPH surveyor asks to see a record, tell the Administrator at once.

What's inside

19 sections. The full text comes with the One-time Policy Pack.

Full text with a package
  • Terms of Reference
  • 1. Purpose
  • 2. Scope
  • 3. Definitions
  • 4. Policy Statement (22 CCR §74888; 42 CFR §418.104)
  • 5. Information Governance (22 CCR §74888(b))
  • 6. The Eight Record Activities (22 CCR §74888(c))
  • 7. Access 24 Hours a Day (22 CCR §74888(d)-(e); §74808(e)-(f))
  • 8. What Every Record Contains (22 CCR §74892)
  • 9. How the Record Is Organized (Indexing)
  • 10. Making Entries (22 CCR §74896(d)-(f); 42 CFR §418.104(b))
  • 11. Records of Care Given Away From the Home
  • 12. Responsibilities
  • 13. Records and Compliance Monitoring
  • 14. Staff Training
  • 15. References
  • 16. Related Policies and Forms
  • 17. Approval
  • 18. Revision History

An inspector may ask

  • Show me how your medical record system is organized and how authorized staff reach a record at 2 a.m.
  • Walk me through your reconciliation and deficiency analysis when a patient is discharged or dies.

See Cura Core with your agency's name on it.

Choose your state and type of agency, buy your Policy Pack online and get your sign-in by email. Already a customer? Sign in to your portal.

Get startedSign in