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Clinical Records: Content, Authentication, Retention, and Protection

Sets what goes in every patient’s clinical record, how entries are written, authenticated, dated, timed and corrected, how paper and electronic records are protected in the office, in the car and in the home, where an out-of-state agency keeps Ohio records, and how long records are kept: the longest of the federal five years after discharge, Ohio Medicaid’s six years from payment or until an audit closes, and the Agency’s own seven-year standard.

Preview: full text with a package
About this policy
Policy number
OH-HH-REC-01
Version
1.0
Main rule
42 CFR §484.110
Library
Ohio home health · 59 policies
Category
Records
Sections
23

In short

  • Write every visit note yourself, accurately, and finish and sign it by the end of the day of the visit, never later than the next business day.
  • Your electronic log-in is your signature. Never share it or sign for anyone else.
  • Never erase or delete. Correct an entry with the record’s amendment tool, and label late entries.
  • Keep paper out of sight and locked away in the car, and leave only the home folder in the patient’s home.
  • Records are kept at least seven years after discharge. Report a lost record or folder to the office the same day.

What's inside

23 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)
  • 5. Contents of the Clinical Record
  • 6. Documentation Standards
  • 7. Timeliness
  • 8. Electronic Records and Signatures
  • 9. Corrections, Late Entries, and Addenda
  • 10. Protecting the Record
  • 11. Where Records Are Kept
  • 12. Retention
  • 13. Requests from Regulators and Payers
  • 14. If the Agency Stops Operating
  • 15. Destruction
  • 16. Responsibilities
  • 17. Records and Compliance Monitoring
  • 18. Staff Training
  • 19. References
  • 20. Related Policies and Forms
  • 21. Approval
  • 22. Revision History

An inspector may ask

  • Show me the clinical record for this patient. Where are the comprehensive assessment, plan of care, orders and visit notes?
  • How does a nurse authenticate an entry, and how is a late entry or a correction made in your electronic record?

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