Clinical Records, Retention and Patient List
Sets out how the Agency keeps one complete, accurate and secure clinical record for every hospice patient: what goes in it, how entries are made, signed and corrected, where active records are kept, how long records are retained, how records are released and retrieved, what is sent when a patient is transferred or discharged, and how the current patient list is maintained.
About this policy
- Policy number
- TX-HSP-REC-01
- Version
- 1.0
- Main rule
- 42 CFR §418.104
- Library
- Texas hospice · 59 policies
- Category
- Records
- Sections
- 20
In short
- Write your visit note the same day you see the patient, and sign only your own notes.
- Never use correction fluid or tape. Strike through an error with one line, then add the date and your initials.
- Take only the papers you need into the field, keep them out of sight, and never leave them in your car overnight.
- Original records of current patients stay at our office. Do not take them home.
- We keep every patient record for at least six years after death or discharge. Never throw a record away yourself.
What's inside
20 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (42 CFR §418.104; 26 TAC §558.301)
- 5. What the Record Contains
- 6. Making Entries
- 7. Corrections and Late Entries
- 8. Storage, Removal and Access
- 9. Transfer, Revocation and Discharge
- 10. Retention and Destruction
- 11. Records Damaged in a Disaster
- 12. Patient List
- 13. Responsibilities
- 14. Records and Compliance Monitoring
- 15. Staff Training
- 16. References
- 17. Related Policies and Forms
- 18. Approval
- 19. Revision History
An inspector may ask
- Show me the clinical record for this patient, including the signed election statement, the notice of rights and the current plan of care.
- When was this visit made, and when was the note incorporated into the record?
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