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Clinical Records: Content, Authentication, Retention, and Protection

Sets out what every clinical record must contain, how entries are written, signed, dated, timed and corrected, how quickly visit notes, discharge summaries and transfer summaries are completed, how records are stored and protected against loss and unauthorized use, and how long they are kept (at least six years after discharge), under 42 CFR §484.110 as adopted by 19 CSR 30-26.010(1)(A) and the MO HealthNet documentation and retention rules in 13 CSR 70-3.030.

Preview: full text with a package
About this policy
Policy number
MO-HH-REC-01
Version
1.0
Main rule
42 CFR §484.110 (adopted by 19 CSR 30-26.010(1)(A))
Library
Missouri home health · 57 policies
Category
Records
Sections
21

In short

  • Document every visit under your own login, with the date and time, by the end of the next business day.
  • Describe this visit only. Do not copy and paste an earlier note.
  • Never change or delete an entry. Add a dated correction or late entry with your name.
  • Discharge summaries go out within 5 business days; transfer summaries within 2 business days.
  • Keep records locked and devices with you. We keep clinical records at least six years after discharge.

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 (42 CFR §484.110; 13 CSR 70-3.030)
  • 5. Contents of the Clinical Record
  • 6. Writing and Signing Entries
  • 7. Corrections and Late Entries
  • 8. Completion Time Frames
  • 9. Storage, Protection, and Availability
  • 10. Access by the Department, Payers, and Other Authorized Reviewers
  • 11. Retention and Destruction
  • 12. Destroying Records at the End of the Retention Period
  • 13. Record Review
  • 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 clinical record for this patient. Where are the comprehensive assessment, the plan of care, the orders and the visit notes?
  • How do staff sign electronic entries, and how do you correct an error in a note?

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