Clinical Records: Content, Timeliness, Protection, and Retention
Requires a clinical record for every patient that holds everything Georgia lists in Ga. Comp. R. & Regs. 111-8-31-.09(d), with clinical notes written the day service is given and filed at least weekly; sets the rules for signing, correcting, storing, moving, and releasing records; and keeps records for six years after the last encounter (adults) or six years after a minor reaches the age of majority, with diagnostic items kept ten years under O.C.G.A. §31-33-2.
About this policy
- Policy number
- GA-HH-REC-01
- Version
- 1.0
- Main rule
- Ga. Comp. R. & Regs. 111-8-31-.09(d)
- Library
- Georgia home health · 56 policies
- Category
- Records
- Sections
- 20
In short
- Write your visit note the same day you see the patient. Sync and sign it within 24 hours; Georgia allows no more than a week.
- Every note shows the date and time, what you found, what you did, how the patient responded, and any change. Sign it with your own log-in.
- Never erase or write over an entry. Use the amendment function, or one line through a paper error with your initials and the date.
- Leave only what the patient needs in the home folder, and never another patient’s papers.
- Records are kept at least six years after the last visit, longer for children, so never destroy anything yourself.
- Do not write in the record that you filled out an incident report. Chart the facts and the care you gave.
What's inside
20 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (Ga. Comp. R. & Regs. 111-8-31-.09(d) to (f))
- 5. Contents of the Clinical Record
- 6. Writing, Signing, and Correcting Entries
- 7. Services Under Arrangement
- 8. Storage, Use, and Removal of Records
- 9. Transfer and Release of Information
- 10. Retention and Destruction
- 11. Destruction
- 12. Dissolution or Change of Ownership
- 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 the clinical record for this patient. Where are the plan of treatment, the physician’s orders, the case conference notes, and the summary reports sent to the physician?
- Was this clinical note written the day the visit was made? When was it incorporated into the record?
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