Clinical Records: Content, Authentication, Timeliness, and Retention
Sets out what the Agency keeps in the clinical record of every patient (42 CFR §484.110), how entries are written, timed, authenticated and corrected, the discharge and transfer summaries and when they are sent, the extra content Michigan Medicaid requires for its patients, how long records are kept (at least seven years after discharge as the Agency’s own standard, which meets the federal five years after discharge, the Michigan Medicaid seven years from the date of service and the seven years Michigan requires of licensed health professionals), and how records are protected, made available and finally destroyed.
- Policy number
- MI-HH-REC-01
- Version
- 1.0
- Main rule
- 42 CFR §484.110
- Library
- Michigan home health · 57 policies
- Category
- Records
- Sections
- 26
In short
- Every patient has one clinical record. Write down what you actually saw, measured and did, with the date and time, and sign it with your own login.
- Finish and sign your visit note by the end of the next business day, and before your next visit to that patient if that comes first.
- Never delete or write over an entry. Use an addendum or a late entry that shows who changed it, when and why.
- Michigan Medicaid patients: the RN co-signs LPN and aide notes, and verbal orders are countersigned before the claim goes out.
- The discharge summary goes to the next practitioner within 5 business days; a transfer summary goes within 2 business days.
- Records are kept at least seven years after discharge. Keep any paper you carry out of sight and bring it back or scan it.
What's inside
26 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (42 CFR §484.110)
- 5. Contents of the Clinical Record
- 6. Documentation Standards
- 6.1 Timeliness of Entries
- 6.2 Authentication and Electronic Signatures
- 6.3 Co-Signatures for Michigan Medicaid Patients
- 6.4 Corrections and Late Entries
- 7. Discharge and Transfer Summaries
- 8. Orders and Plans of Care in the Record
- 9. Retention of Clinical Records
- 9.1 Legal Holds
- 9.2 Retention if the Agency Stops Operating
- 10. Storage, Protection and Availability
- 11. Clinical Record Review
- 12. Destruction at the End of the Retention Period
- 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 complete clinical record for this patient, including the comprehensive assessment, plan of care, orders, visit notes and discharge summary.
- How do staff authenticate entries, and how do you correct an error in the electronic record?
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