Medical Records: Content, Handling and Retention
Sets out what every hospice medical record contains, how entries are made, dated and authenticated, where originals and copies are kept, the five-working-day return and sign-out log for records removed for the annual evaluation, release of records, and a single retention rule that meets the North Carolina three-year and minor periods, the federal six-year period and the Medicare seven-year period for order and certification documentation.
About this policy
- Policy number
- NC-HSP-REC-01
- Version
- 1.0
- Main rule
- 10A NCAC 13K .0902
- Library
- North Carolina hospice · 60 policies
- Category
- Records
- Sections
- 29
In short
- Chart every visit on the day you make it, with your own login and signature. Never sign or chart for someone else.
- If you write about something that happened on an earlier day, label it "Late entry" and give both dates.
- Correct mistakes with the EHR amendment tool or a single line on paper. Never erase or back-date.
- Original records stay on the licensed premises. A record taken out for the annual evaluation goes on the sign-out log and comes back within five working days.
- Leave only copies in the home folder: care plan, medication list, emergency plan and phone numbers.
- Records are kept at least 7 years after death or discharge, longer for minors. Send release requests to the Privacy Official.
What's inside
29 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 13K .0902)
- 5. What Every Record Contains
- 5.1 Federal content (if the Agency is Medicare-certified)
- 5.2 Other documents kept in the record
- 6. Making Entries
- 6.1 Late and out-of-sequence entries
- 6.2 Corrections
- 6.3 Electronic records and signatures
- 7. Originals, Copies and Where Records Are Kept
- 7.1 Notes from contracted providers and facilities
- 8. Records Removed for the Annual Evaluation
- 9. Department Access and the Statement Denying Access
- 10. Retention
- 10.1 Other retention rules that touch the record
- 11. Discharge, Transfer and Death
- 12. Releasing Records
- 13. Storage and Destruction
- 14. Records if the Agency Closes
- 15. Responsibilities
- 16. Records and Compliance Monitoring
- 17. Staff Training
- 18. References
- 19. Related Policies and Forms
- 20. Approval
- 21. Revision History
An inspector may ask
- Show me a complete record for a current patient and for a patient who died last year. Where is the signed rights form and the consent for care?
- How do you mark a late entry? Show me one.
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