Skip to content

Patient Access to Records, Copies, Release of Information, and Record Removal

Gives every patient a free copy of the clinical record at the next home visit or within 4 business days, whichever comes first, sets out how other access requests, authorizations, subpoenas and requests from the Division of Health Service Regulation are handled, and requires a sign-out log and return within five working days for any original record removed from the licensed premises for an evaluation.

Preview: full text with a package
About this policy
Policy number
NC-HH-REC-02
Version
1.0
Main rule
42 CFR §484.110(e)
Library
North Carolina home health · 57 policies
Category
Records
Sections
17

In short

  • A patient may ask any of us for a copy of his or her record. Write down the date of the request and tell the office the same day.
  • The patient gets the clinical record free of charge at the next home visit or within 4 business days, whichever comes first.
  • Never hand records to lawyers, police, insurers or relatives who are not on the approved list. Take their name and number and refer them to the office.
  • Never take an original paper record to a patient’s home or to your own home. Work in the electronic record and the home folder copy.
  • An original record taken off the premises for an evaluation is signed out on the log and must be back within five working days.

What's inside

17 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(e); 45 CFR §164.524; 10A NCAC 13J .1401(c), (d))
  • 5. Patient Requests to See or Copy Records
  • 6. Releases to Other People and Organizations
  • 7. The Division of Health Service Regulation, CMS and Other Oversight Bodies
  • 8. Subpoenas, Court Orders and Law Enforcement
  • 9. Removing Original Records from the Premises
  • 10. Responsibilities
  • 11. Records and Compliance Monitoring
  • 12. Staff Training
  • 13. References
  • 14. Related Policies and Forms
  • 15. Approval
  • 16. Revision History

An inspector may ask

  • A patient asked for a copy of her record yesterday. When will she get it, and what will she pay?
  • Show me the sign-out log for records taken off the premises.

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