Policy Manual sample

MDT Home Health Care Agency, Inc. processes including Intake RN's, Coordinators, Schedulers and Billing staff. 2. Clinical staff should only have access to information on those clients to which they are actively providing care and service, such as primary nurses, on-call, relief, etc. 3. Office staff should only have access to information on those clients they are actively providing service to, such as working on bills, following up on complaints, etc. 4. Access to records for individuals from outside the organization, such as surveyors, reviewers, consultants, etc. will be approved by the Administrator and/or Director of Nursing, Clinical Manager on a per occurrence basis providing they have appropriate identification. 5. Any Agency committee may review the clinical record at meetings as requested by the Administrator or Director of Nursing, Clinical Manager. 6. Any release of information contained in the clinical record other than that required by law must be authorized in writing by the client. 7. Review of the clinical record for the purposes of performance improvement activities (QAPI) and clinical record review will be performed according to Agency policy. When the patient/client is transferred to another health care facility, a transfer form or a discharge summary or pertinent information is sent to the attending physician and facility. Records and information pertaining to persons with AIDS shall be handled in accordance with state laws and the Agency policies. Patient/Client Access to Records Patients/clients wishing to review the contents of their clinical record must submit a written request to the Administrator, and will have access under any circumstance. The request must identify the specific portions of the record to be reviewed. The Administrator or designee shall be present at all times during the review. Patient, legal representative (if any) can ask to see or get an electronic or paper copy of patient medical record and other health information we have about them. We will provide a copy or a summary of your health information, usually within 4 business days of your request. Free of charge. If, after reviewing his/her record the patient/client/legal guardian feels there is a mistake, notation of such should be dated and documented on a separate note and attached to the patient's/client’s record. No alteration of the original record by crossing out and initialing should be made. If the patient/client wishes to amend the records, documentation by the patient/client will be accepted and included in the record. Release of Information Upon admission, the patient/client or his legal representative shall sign an authorization for the Agency to request and to release medical information. The authorization may indicate certain information which cannot be released and may also specify persons or entities to whom information may not be released, if the patient/client so desires. The patient/client or legal guardian may consent to release of his/her records. The Agency must respond to such request, however, the following guidelines will apply: Home Health Agency Policies A-106