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Medical Records and Retention

Sets out how the Agency keeps one complete, accurate and secure medical record for every hospice patient: what the record contains, how entries are signed and dated on the day of service and filed within seven days, how errors are corrected, how records are stored, produced for the Department and released under Georgia and federal law, what is sent when a patient is transferred, revokes or is discharged, and how long records are kept.

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About this policy
Policy number
GA-HSP-REC-01
Version
1.0
Main rule
Ga. Comp. R. & Regs. 111-8-37-.23
Library
Georgia hospice · 60 policies
Category
Records
Sections
21

In short

  • Write a note for every service you give, and sign and date it the same day.
  • Make sure your note is in the patient’s record within seven days. Notes from contractors and facilities count too.
  • Never use correction fluid. Strike through errors with one line, date and initial them.
  • Only take the papers you need into the field, and never leave them in your car overnight.
  • Send every request for records to the office the same day. Georgia gives us 30 days to respond.
  • We keep records at least until the sixth anniversary of death or discharge, and longer for children.

What's inside

21 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 (Ga. Comp. R. & Regs. 111-8-37-.23; 42 CFR §418.104)
  • 5. What the Record Contains
  • 6. Making Entries
  • 7. Corrections and Late Entries
  • 8. Storage, Access and Production to the Department
  • 9. Releasing Records and Copies
  • 10. Transfer, Revocation and Discharge
  • 11. Retention and Destruction
  • 12. If the Agency Closes
  • 13. Records Damaged or Lost
  • 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 the medical record for this patient, including the consent forms, the plan of care and the name of the attending physician.
  • This visit note is dated the 3rd. When was it signed, and when was it placed in the record?

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