Skip to content

Clinical Records: Content, Authentication, Access, and Retention

Sets out how the Agency builds and keeps a complete clinical record for every patient: what goes in it, how entries are written, signed, dated, timed, and corrected, how fast visit notes reach the record, where originals are stored, who may see or take a record, how patients get a free copy, and how long records are kept.

Preview: full text with a package
About this policy
Policy number
TX-HH-REC-01
Version
1.0
Main rule
26 TAC §558.301
Library
Texas home health · 56 policies
Category
Records
Sections
17

In short

  • Write your visit note the same day you see the patient, and sign it with your name, title, date, and time.
  • Fix a paper mistake with one line through it, the date, and your initials. Never use correction fluid or tear out a page.
  • Get your notes to the office quickly. They must be in the record within 14 working days.
  • Do not take a record out of the office without the supervising nurse’s approval.
  • If a patient asks for their record, tell the office the same day. They get a free copy fast.

What's inside

17 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 (26 TAC §558.301)
  • 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, Retention, and Destruction
  • 10. Responsibilities
  • 11. Records and Compliance Monitoring
  • 12. Staff Training
  • 13. References
  • 14. Related Policies and Forms
  • 15. Approval
  • 16. Revision History

An inspector may ask

  • Show me the clinical note for this visit. When was it written, and when was it incorporated into the record?
  • How does a nurse correct a mistake in the paper record, and how does your electronic system show a change?

See Cura Core with your agency's name on it.

Choose your state and type of agency, buy your Policy Pack online and get your sign-in by email. Already a customer? Sign in to your portal.

Get startedSign in