Clinical Records: Content, Authentication, Access, and Retention
Sets out what every clinical record must contain, how entries are written, signed, dated and corrected, how records are protected, used, removed and released, how patients get copies, and how long records are kept: 7 years after discharge under 28 Pa. Code §601.36(b), which is longer than the 5-year federal minimum in 42 CFR §484.110(c) and the 4-year Medical Assistance minimum in 55 Pa. Code §1101.51(e).
About this policy
- Policy number
- PA-HH-REC-01
- Version
- 1.0
- Main rule
- 28 Pa. Code §601.36
- Library
- Pennsylvania home health · 56 policies
- Category
- Records
- Sections
- 18
In short
- Write your visit note on the day of the visit, and sign and date it. Notes must be filed in the record at least weekly.
- Never erase or white out. Correct paper notes with a single line, the date and your initials; use an addendum in the electronic record.
- Patient records are privileged and confidential. A record leaves the office only with the supervising nurse’s approval and is signed out.
- Patients may get a copy of their record. Pass any request to the office the same day.
- Pennsylvania requires clinical records to be kept for 7 years after discharge.
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 §601.36)
- 5. Contents of the Clinical Record
- 6. Writing, Signing, and Correcting Entries
- 7. Storage, Use, and Removal of Records
- 8. Patient Access to the Record
- 9. Release to Others
- 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 the clinical record for this patient. Where are the plan of treatment, the physician’s name, the activity orders and the summary reports sent to the physician?
- Clinical notes must be written the day of service and filed at least weekly. How do you make sure that happens?
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