Clinical Records: Content, Signatures, Retention, and Transfer
Sets what every clinical record must contain under Rule 59A-8.022, F.A.C., how entries are signed, dated, corrected, and authenticated on paper, by fax, and electronically, how records are kept retrievable for unannounced surveys, how a copy goes to another home health agency when a patient transfers, how long each kind of record is kept (6 years after termination for skilled care under s. 400.491(1), F.S.), how records are destroyed, and what happens to them if the Agency closes. Adds the federal content, transfer and discharge summary, authentication, and patient copy rules for a Medicare-certified agency.
- Policy number
- FL-HH-REC-01
- Version
- 1.0
- Main rule
- s. 400.491, F.S.
- Library
- Florida home health · 57 policies
- Category
- Records
- Sections
- 22
In short
- Write a note for every visit, and sign and date it. Finish it by the end of the next calendar day.
- Never change or delete an entry. Correct it with a single line, your initials, the date, and the reason, or as the electronic system allows.
- Take into a home only the records you need for that visit, and keep them secure.
- Records of skilled care are kept for 6 years after services end.
- Send every request for a copy of a record to the office so it can be logged and handled correctly.
What's inside
22 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (s. 400.491, F.S.)
- 5. Contents of the Clinical Record
- 5.1 Other items the Agency files
- 5.2 Medicare-certified agencies
- 6. Writing, Signing, and Correcting Entries
- 7. Faxed and Electronic Signatures
- 8. Storage, Retrieval, and Use
- 9. Transfer of the Record and Copies
- 10. Retention
- 11. Destruction
- 12. If the Agency Stops Operating
- 13. Responsibilities
- 14. Records and Compliance Monitoring
- 15. Staff Training
- 16. References
- 17. Related Policies and Forms
- 18. Approval
- 19. Revision History
An inspector may ask
- Show me this patient's clinical record. Where is the source of referral, the identification sheet, and the statement of the caregiver's ability to provide interim services?
- This patient was discharged last year. Show me the termination summary with the reason for termination and the condition of the patient on discharge.
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