Clinical Records, Retention and Access
Sets out what every hospice clinical record contains, how entries are made and authenticated, how records are protected, how long they are kept (6 years after death or discharge under 42 CFR §418.104(d), 10 years for DC Medicaid records as DHCF states, and an Agency standard that meets both), what goes to the next provider at discharge or transfer, and how patients and representatives get access, amendments and an accounting of disclosures.
About this policy
- Policy number
- DC-HSP-REC-01
- Version
- 1.0
- Main rule
- 42 CFR §418.104
- Library
- Washington, DC hospice · 60 policies
- Category
- Records
- Sections
- 20
In short
- Write up every visit and call in the electronic record before the end of the day.
- Sign every entry under your own login. Label late entries and never delete the original.
- The Agency keeps clinical records for at least 10 years after death or discharge.
- Send all requests for copies of records to the privacy official.
- Patients can see or get a copy of their record. The Agency answers within 30 days at most.
- When care ends, the nurse sends a discharge summary to the next facility or the doctor.
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)
- 5. What the Clinical Record Contains
- 6. Making Entries
- 7. Protecting the Record
- 8. Retention
- 9. Destruction
- 10. Discharge, Transfer and Revocation
- 11. Patient Access, Amendment and Accounting of Disclosures
- 12. Releasing the Record to Others
- 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 signed election statement, the notice of rights and the most recent plan of care?
- How do you make sure every entry is authenticated and dated, and how are late entries and corrections made?
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