Clinical Records, Retention and Access

Sets out what every patient’s clinical record must contain, the time by which each discipline’s notes must be in the record under Chapter 82, how entries are signed and corrected, where records are kept and who may use them, how patients and families get access and copies within Louisiana and HIPAA time limits, how information is released, and how long records are kept and then destroyed.

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About this policy

Policy number: LA-HSP-REC-01
Version: 1.0
Main rule: LAC 48:I §8233
Library: Louisiana hospice · 60 policies
Category: Records
Sections: 26

In short

Keep a complete, accurate record for every patient. Sign each entry with your own log-in and never share a password.
Our rule: finish and sign each visit note by the end of the next business day. Louisiana’s outer limit is one week for nurses, social workers and therapists, and weekly for aides, LPNs and assistants.
Never erase or write over an entry. Correct it with an addendum, or on paper with one line, the word “error”, the date and your initials.
Records are kept for at least seven years after discharge or death (Louisiana requires six). Keep them locked and out of sight in the field.
Release information only with the patient’s signed authorization (Form LA-HSP-REC-01-A) or when a law requires it.
Send every request for copies, subpoena or police request to the Privacy Official the same day. Copies go out within 15 days of a complete request.

What's inside

26 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 (LAC 48:I §8233)
5. What the Clinical Record Contains
6. When Each Discipline Documents
7. Entries, Signatures and Corrections
8. Storage, Location and Safeguards
9. Who May Use the Record
10. Patient Access and Copies
10.1 Receiving a request
10.2 Time limits
10.3 Form of copies and charges
10.4 Records of a patient who has died
10.5 Denials and other rights
11. Releasing Information to Others
12. Transfer, Discharge and Records Sent to Others
13. Retention and Destruction
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 this patient’s clinical record, including the certification, election statement, plan of care and the clinical notes for the past 60 days.
How do you make sure nurses, social workers and therapists put their notes in the record within one week of the visit?

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Rules it follows

LAC 48:I §8233LAC 48:I §8241.FLAC 48:I §8217LAC 48:I §8219.C.2LAC 48:I §8221.B.1.bLAC 48:I §8231.A.8LAC 48:I §8237.D.7LAC 48:I §8243.FLAC 48:I §8205.E.6LAC 48:I §8207.A.9LAC 48:I §8207.A.11.cLAC 48:I §8257.E.2R.S. 40:1165.1R.S. 40:1171.4R.S. 51:3074(B)42 CFR §418.10442 CFR §418.108(c)(3)42 CFR §424.516(f)45 CFR §164.50845 CFR §164.510(b)45 CFR §164.52445 CFR §164.530(j)

Forms included

LA-HSP-REC-01-A Authorization to Release Health Information

Read a sample in full

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