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Central Clinical Record, Retention and Electronic Signatures

Sets how the Agency keeps one central clinical record for each patient and family under ORC 3712.06(G) and OAC 3701-19-23: what every record contains, how entries are made, dated and signed (including electronic signatures that meet ORC 3701.75), how records are stored and protected, who may see them, what is sent on transfer or discharge, and how long records are kept when Ohio's hospice rules set no retention period.

Preview: full text with a package
About this policy
Policy number
OH-HSP-REC-01
Version
1.0
Main rule
OAC 3701-19-23
Library
Ohio hospice · 60 policies
Category
Records
Sections
25

In short

  • Every visit, call and service goes into the patient's one central clinical record, including notes from volunteers and contracted facilities.
  • Complete and sign your visit note on the day of the visit, and no later than 24 hours after it.
  • Sign only under your own login. Never share your password or sign for someone else.
  • Correct a mistake with a dated addendum; never delete, erase or overwrite an entry.
  • Keep paper records locked and out of sight, and leave only the home folder items in the patient's home.
  • Send every request for copies from outside the Agency to the privacy official.

What's inside

25 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 (ORC 3712.06(G); OAC 3701-19-23; 42 CFR §418.104)
  • 5. One Central Record for Each Patient and Family
  • 6. What Every Record Contains
  • 7. How Entries Are Made
  • 7.1 Agency time frames for documentation
  • 7.2 Rules for every entry
  • 8. Electronic Records and Electronic Signatures
  • 9. Storage and Protection
  • 10. Who May See the Record
  • 11. Transfer and Discharge
  • 12. How Long Records Are Kept
  • 12.1 Destruction
  • 12.2 If the Agency closes
  • 13. Subpoenas, Court Orders and Legal Requests
  • 14. Responsibilities
  • 15. Records and Compliance Monitoring
  • 16. Staff Training
  • 17. References
  • 18. Related Policies and Forms
  • 19. Approval
  • 20. Revision History

An inspector may ask

  • Show me the central clinical record for this patient, including the visit notes of your contracted inpatient facility and your volunteers.
  • How does your electronic signature system meet ORC 3701.75? Show me the written user certification for this nurse.

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