Participant Records, Service Documentation, and Retention
Sets out what goes into every participant case record, how service entries are made, corrected and stored, who may see the record, how fast copies go to MO HealthNet and the state agencies, how long each kind of record is kept (six years from the date of service and six years after the participation agreement expires, whichever is later, never less than five years), and how records are destroyed.
About this policy
- Policy number
- MO-HC-REC-01
- Version
- 1.0
- Main rule
- 19 CSR 15-7.021(24)
- Library
- Missouri home care · 50 policies
- Category
- Records
- Sections
- 19
In short
- Record every visit and task in EVV at the visit, exactly as it happened. Never enter times or tasks in advance or for someone else.
- Entries must be made at the time of service, and never later than five business days after.
- To correct a record, add a dated entry with your name. Never erase, white out or change the original.
- Keep your copy of the care plan private and in a closed folder or the EVV app. Do not leave it in your car where it can be seen.
- Participant records are kept at least six years, and longer while any audit or investigation is open. Never throw a record away yourself.
What's inside
19 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (19 CSR 15-7.021(24))
- 5. Contents of the Participant Case Record
- 6. Documenting Each Service
- 7. Corrections, Late Entries and Adjustments
- 8. Storage, Confidentiality and the Central Location
- 9. Access to Records and Requests for Copies
- 10. Retention
- 11. Destruction of Records
- 12. Responsibilities
- 13. Records and Compliance Monitoring
- 14. Staff Training
- 15. References
- 16. Related Policies and Forms
- 17. Approval
- 18. Revision History
An inspector may ask
- Show me the case record for this participant. Where is the date you received the authorization?
- Where do you document units that were authorized but not delivered, and why?
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