Interdisciplinary Record of Care, Retention and Release of Records
Sets what goes in each patient’s interdisciplinary record of care, how entries are made, corrected and stored, who may obtain a copy under the strict Florida release rule in s. 400.611(4), F.S., how the patient’s own HIPAA right of access is met, what is sent on transfer or discharge, and how long records are kept (at least 7 years after hospice services end, which meets the Florida 6-year rule, the Medicare 6-year rule and the 7-year Medicare enrollment rule).
About this policy
- Policy number
- FL-HSP-REC-01
- Version
- 1.0
- Main rule
- s. 400.611, F.S.
- Library
- Florida hospice · 60 policies
- Category
- Records
- Sections
- 25
In short
- Write down every visit and call in the record by the end of the next business day; same day for falls, errors and changes in condition.
- Never change, back-date or remove an entry. Correct mistakes so the original still shows.
- Florida law is strict: no record leaves the Agency without a signed patient authorization, a court order or the other papers the law lists.
- Send every records request, subpoena or lawyer’s letter to Lee Sample. Do not hand over copies yourself.
- Keep paper notes closed and out of sight, and never leave them in your car.
- Records are kept at least 7 years after hospice services end.
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 (s. 400.611, F.S.; 42 CFR §418.104)
- 5. What the Record Contains
- 6. Making Entries
- 7. Storage, Location and Protection
- 8. Access by AHCA and Other Authorities
- 9. Releasing Records Outside the Agency
- 9.1 Release procedure
- 9.2 The patient’s own access
- 9.3 Sharing that is not a release
- 10. Transfer, Revocation and Discharge
- 11. Retention and Destruction
- 11.1 Destruction
- 12. If the Agency Closes
- 13. Lost, Damaged or Unavailable Records
- 14. Responsibilities
- 15. Records and Compliance Monitoring
- 16. Staff Training
- 17. References
- 18. Related Policies and Forms
- 19. Approval
- 20. Revision History
An inspector may ask
- Show me a complete interdisciplinary record of care for a current patient and one for a patient whose services ended.
- How long do you keep records, and how do you keep records of minors?
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