Clinical Records: Content, Authentication, Storage, and Retention
Defines what goes into every patient’s clinical record, how entries are written, signed, corrected, and kept secure, where records are held (the District operating office, or produced within 24 hours), how long they are kept (at least five years after discharge under Chapter 39, ten years for DC Medicaid records, and ten years after discharge for every record as the Agency’s own standard), and how they are destroyed or transferred if the Agency closes.
About this policy
- Policy number
- DC-HH-REC-01
- Version
- 1.0
- Main rule
- 22-B DCMR §3910.4
- Library
- Washington, DC home health · 58 policies
- Category
- Records
- Sections
- 23
In short
- Write your visit note or activity record during or right after the visit, and get it into the record by the end of the next business day.
- Sign every entry with your own name and title or your own login. Never sign or log in for someone else.
- To fix a mistake, draw one line through it or use the amendment function, then date and initial it. Never erase or delete.
- Carry only the papers you need, keep them in a closed folder, and never leave them in your car.
- Records are kept at least ten years after discharge. Never throw a record away yourself.
What's inside
23 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (22-B DCMR §3910 and §3911)
- 5. What Every Clinical Record Contains
- 5.1 Additional contents for a Medicare-certified agency
- 5.2 Additional contents for DC Medicaid personal care aide services
- 5.3 Additional contents for EPD Waiver services
- 6. How Entries Are Written
- 7. Corrections and Late Entries
- 8. Where Records Are Kept
- 9. Protecting Records
- 10. How Long Records Are Kept
- 11. Secure Destruction
- 12. If the Agency Is Dissolved
- 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. Where are the physician’s orders, the medication sheet, and the aide activity records?
- Where are the nurse’s progress notes for the last 30 days and the last summary note?
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