Clinical Records, Retention and Access
Sets out what every Missouri hospice clinical record must contain, how and when staff make, sign and correct entries, how records are organized, stored and safeguarded, who may see them and how quickly copies are produced, what goes with a patient on transfer or discharge, and how long records are kept. The Missouri hospice rule sets no retention period, so the Agency keeps clinical records for six years after death or discharge or six years from the last date of service billed to MO HealthNet, whichever is later.
About this policy
- Policy number
- MO-HSP-REC-01
- Version
- 1.0
- Main rule
- 19 CSR 30-35.010(2)(K)
- Library
- Missouri hospice · 59 policies
- Category
- Records
- Sections
- 20
In short
- Write up every visit and phone call yourself, under your own log-in, by the end of the day and never later than the end of the next day.
- Never erase or delete. Correct a mistake with a single line or the system's amendment tool, and date and sign it.
- Keep records locked or on encrypted devices. Leave only the home folder in the patient's home.
- Send any request for records from a patient, family, lawyer or agency to the privacy official.
- Records are kept at least six years after death or discharge, and longer for MO HealthNet services.
What's inside
20 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 30-35.010(2)(K))
- 5. What Every Clinical Record Contains
- 6. Making Entries
- 7. Corrections, Late Entries and Addenda
- 8. Organization, Storage and Safeguarding
- 9. Access to Records
- 10. Transfer, Revocation, Discharge and Inpatient Admission
- 11. Retention and Destruction
- 12. Records Lost or Damaged, and Records After Closure
- 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 this patient's complete record, including the consent form, the determination of financial responsibility and the communication with coordinating providers.
- How do you make sure entries for contracted services, such as inpatient stays, end up in your record?
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