Skip to content

Clinical Records, Administrative Records, Retention and Access

Sets out what goes into each patient's clinical record, how entries are made and authenticated, how records are kept secure and available to staff, physicians and Department surveyors, how long clinical and administrative records are kept under Michigan law and the Medicare rules, how records are destroyed, and how patients and their representatives see, copy and ask to amend their records under the Michigan Medical Records Access Act and HIPAA.

Preview: full text with a package
About this policy
Policy number
MI-HSP-REC-01
Version
1.0
Main rule
MCL 333.20175
Library
Michigan hospice · 59 policies
Category
Records
Sections
22

In short

  • Write your visit note during the visit or before your workday ends. Never sign for someone else or share your login.
  • Do not erase or delete mistakes. Correct them so the original can still be read.
  • Keep records locked away and never leave them visible in your car.
  • If a patient or family asks for records, give them the request form and tell the office the same day. The Agency must answer within 30 days.
  • Records are kept at least 7 years after death or discharge. Never throw records away yourself.

What's inside

22 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 (MCL 333.20175; Mich. Admin. Code R 325.45191; 42 CFR §418.104)
  • 5. What Each Record Contains
  • 6. Making Entries
  • 7. Records in the Patient's Home or Residence
  • 8. Availability, Storage and Security
  • 9. Access by the Department and Other Authorities
  • 10. Retention
  • 11. Destruction
  • 12. Patients' Right to See and Copy Their Records
  • 13. Requests to Amend a Record
  • 14. Transfer, Revocation and Discharge
  • 15. Responsibilities
  • 16. Records and Compliance Monitoring
  • 17. Staff Training
  • 18. References
  • 19. Related Policies and Forms
  • 20. Approval
  • 21. Revision History

An inspector may ask

  • Show me this patient's record: where are the terminal prognosis, the signed election statement, the notice of rights and the physician orders?
  • How long do you keep a record after the patient dies, and how do you destroy records?

See Cura Core with your agency's name on it.

Choose your state and type of agency, buy your Policy Pack online and get your sign-in by email. Already a customer? Sign in to your portal.

Get startedSign in