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Clinical Records, Retention and Access

Sets out what goes into every patient's clinical record, how entries are made, signed and corrected, how records are stored, protected and produced for the Department of Health, what is sent when a patient is transferred, revokes or is discharged, and how long records are kept. Pennsylvania has no hospice record rule of its own, so the federal clinical record condition applies as a licensure standard, with the Medical Assistance record standards added for MA recipients.

Preview: full text with a package
About this policy
Policy number
PA-HSP-REC-01
Version
1.0
Main rule
42 CFR §418.104
Library
Pennsylvania hospice · 60 policies
Category
Records
Sections
20

In short

  • Document every visit and call in the electronic record the same day, and sign only your own entries with your own log-in.
  • Write facts: what you saw, heard, did and taught, and how the patient responded. No opinions, and never mention an incident report.
  • Never erase or overwrite. Correct with a dated, signed change or a labeled late entry.
  • Take only the papers you need into the field, keep them out of sight, and never leave them in your car overnight.
  • Records are kept at least 6 years after death or discharge. Surveyors may ask to see any record, and we produce it the same day.

What's inside

20 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 §418.104)
  • 5. What the Record Contains
  • 6. Making Entries
  • 7. Corrections and Late Entries
  • 8. Storage, Field Papers and Access
  • 9. Transfer, Revocation and Discharge
  • 10. Retention and Destruction
  • 10.1 Destruction
  • 11. Records in an Emergency
  • 12. Responsibilities
  • 13. Records and Compliance Monitoring
  • 14. Staff Training
  • 15. References
  • 16. Related Policies and Forms
  • 17. Approval
  • 18. Revision History

An inspector may ask

  • Show me where in this record I find the signed notice of rights, the signed election statement, the certifications and the physician orders.
  • How are late entries and corrections made in your electronic record?

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