Policy Manual sample

MDT Home Health Care Agency, Inc. be protected from loss and unauthorized use, also we will comply with all HIPAA regulations and laws, and we will maintain a Log of authorized retrieve/return of any record, signed by requester staff. Patient/client clinical records will be maintained in the Agency (with pertinent information maintained in the patient's/client’s residence as indicated) and will be available to administrative, service delivery and clerical staff who require the use of records in the performance of Agency services or their job requirements. Such staff may use the records and make entries pertinent to the performance of their job. Original copies of all active patient records are kept in a secure location on the Agency’s premises. Current electronic patient records are stored in an appropriate secure manner as to maintain the integrity of the patient data through routine backups on or off-site. The protection and access of computerized records and information, including back-up procedures must be always followed that included daily security backup, electronic transmission procedures must be secured, an anti-virus software installed, the storage of back-up disks and tapes will be secured, and off site, the methods to replace information if necessary will be always follow the backup/restore guidelines of the backup system manufacturer. Entries in the patient record are authenticated by the author. Information introduced into the patient record through transcription or dictation is authenticated by the author. Note 1: Authentication can be verified through electronic signatures, written signatures or initials, rubber-stamp signatures, or computer key. Note 2: For paper-based records, signatures entered for purposes of authentication after transcription or for verbal orders are dated when required. For electronic records, electronic signatures will be date-stamped. Billing records will be maintained in the Agency and will be available to administrative, financial and clerical staff who require the use of records in the performance of Agency services or their job requirements. Such staff may use the records and make entries pertinent to the performance of their job. Records will be made available to properly authorized state and federal Agency staff and accreditation representatives for the purpose of Agency audits and certification, licensure and accreditation reviews, following HIPAA guidelines. In order to promote uniformity concerning confidentiality, security and integrity of the Agency's home health care information for all home health care staff, only authorized home care staff will have access to the home health care record as follows: 1. Access to patient/client information files (medical records and billing) will be limited to Agency staff involved in the care/service of the patient/client and may include: a. Administrative staff; b. Clinical Supervisors; c. Clinical staff (direct and through contract) including RN's, LPN's, HHA's, PT's, OT's, ST's, MSW's, RRT; nutritionists d. Office staff having a need to know to perform their home care functions and Home Health Agency Policies A-105