Policy Manual sample

MDT Home Health Care Agency, Inc. POLICY ON CLINICAL RECORDS POLICY: Regulate a Content, Maintenance/Retention, Signatures of Patient’s/Client’s Clinical Records A clinical record will be maintained for each patient receiving professional skilled services (nursing or therapy services) that includes all the services provided directly by the employees of the home health agency and those provided by contracted individuals or agencies. No information may be disclosed from the patient * s file without the written consent of the patient or the patients guardian. All information received by any employee, contractor, or AHCA employee regarding a patient of the home health agency is confidential and exempt from Chapter 119, F.S. If the patient transfers to another home health agency, a copy of his record must be transferred at his request. Our HHA will maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. (a) Standard: Contents of clinical record. The record must include: (1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician orders; (2) All interventions, including medication administration, treatments, and services, and responses to those interventions; (3) Goals in the patient’s plans of care and the patient’s progress toward achieving them; (4) Contact information for the patient, the patient’s representative (if any), and the patient’s primary caregiver(s); (5) Contact information for the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA; and (6)(i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. (b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. (c) Standard: Retention of records. (1) Clinical records must be retained for 5 years after the discharge of the patient, unless state law stipulates a longer period of time. (2) The HHA’s policies must provide for retention of clinical records even if it discontinues operation. When an HHA discontinues operation, it must inform the state agency where clinical records will be maintained. Home Health Agency - - Skilled Professional Services C-17