Consumer Records and Documentation of Services
Sets out what goes in each consumer record, how direct care workers document every visit, how entries are corrected, how electronic records are kept, who may see records, and how long records are kept before secure destruction. Chapter 611 sets no record contents or retention period, so the Agency’s own standards are stated, together with the documentation the Department of Health inspects under §611.57(d) and the Medical Assistance retention periods for waiver services.
About this policy
- Policy number
- PA-HC-REC-01
- Version
- 1.0
- Main rule
- 28 Pa. Code §611.57(d)
- Library
- Pennsylvania home care · 49 policies
- Category
- Records
- Sections
- 18
In short
- Complete your visit note at every visit, before you leave, with your real arrival and departure times.
- Mark every task done, not done or refused, and say why if it was not done.
- Write facts only. If you notice a change, an injury or a concern, call the office too.
- To fix a paper mistake, draw one line through it, write the correction, and initial and date it. Never erase or use correction fluid.
- Never change, back-date or throw away a record. Keep records in the home private.
What's inside
18 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (28 Pa. Code §611.57(d))
- 5. Contents of the Consumer Record
- 6. Documenting Visits
- 7. Rules for Every Entry
- 8. Electronic Records
- 9. Access, Storage, and Records in the Home
- 10. Retention and Destruction
- 11. Responsibilities
- 12. Records and Compliance Monitoring
- 13. Staff Training
- 14. References
- 15. Related Policies and Forms
- 16. Approval
- 17. Revision History
An inspector may ask
- Show me this consumer’s record: the information packet, the signed acknowledgment, the service plan and the last month of visit notes.
- How does a worker correct a mistake in a visit note?
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