Service Records: Content, Entries, Completion and Return, and Retention
Sets out what every patient’s service record contains, how entries are dated, authenticated and corrected, the Agency’s time frame for completing and returning service records, where originals are kept, and how long records are kept: at least six years after discharge for every patient (the NC Medicaid period, which is longer than the five years in 10A NCAC 13J and 42 CFR §484.110), longer for minors, and seven years from the date of service for orders, certifications and claims.
About this policy
- Policy number
- NC-HH-REC-01
- Version
- 1.0
- Main rule
- 10A NCAC 13J .1401
- Library
- North Carolina home health · 57 policies
- Category
- Records
- Sections
- 19
In short
- Every page or screen of the record shows the patient’s name, and every entry shows the real date you made it.
- Finish and sign your visit note the same day as the visit. Paper notes and papers signed in the home go back to the office within 2 business days (Agency standard).
- Mark a late note “late entry”, “addendum” or “entry out of sequence” with the date you write it. Never back-date, erase or write over an entry.
- Never sign for someone else or share your log-in. If you copy text from an earlier note, edit it so it describes only this visit.
- Records are kept at least 6 years after discharge, and longer for children. Never throw away a patient paper yourself; give it to the office.
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 (10A NCAC 13J .1401; 42 CFR §484.110)
- 5. One Record for Each Patient, Originals and Copies
- 6. What the Record Contains
- 7. Entries, Authentication and Corrections
- 8. Completion and Return of Service Records
- 9. Availability, Location and Security
- 10. Purging (Thinning) Long Records
- 11. Retention and Destruction
- 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 this patient’s record. Where are the signed rights form, the referral source, the assessment of the home environment and the physician’s orders?
- How do staff mark a late entry, and how do you correct an error in the electronic record?
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