Policy Manual sample

MDT Home Health Care Agency, Inc. (d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. (e) Standard: Retrieval of clinical records. A patient’s clinical record (whether hard copy or electronic form) must be made available to a patient, free of charge, upon request at the next home visit, or within 4 business days (which ever comes first). Clinical records also may contain the following: 1. Source of referral, Diagnosis 2. Physician’s, [ARNP, PA] (acting within their respective scope of practice) verbal order initiated by the physician [ARNP, PA] (acting within their respective scope of practice) prior to start of care and signed by the physician before the agency bill the services. a. Physician orders that included medications, dietary, treatment and activity orders. 3. Assessment of the patient’s needs (including OASIS assessment if applicable), Admission and informed consents documents, assessment of the home (if applicable) 4. Statement of patient or caregiver problems 5. Statement of patient’s and caregiver’s ability to provide interim services 6. Identification sheet for the patient with name, address, telephone number, date of birth, sex, agency case number, caregiver, next of kin or guardian 7. Plan of Care and all subsequent updates and changes 8. Clinical and service notes, signed and dated by the staff member providing the service which shall include: - Initial assessment (OASIS if applicable) and clinical notes with changes in the person’s condition - Services rendered - Observations - Instructions to the patient and caregiver or guardian, including administration of and adverse reactions to medications 9. Home visits to patients for supervision of staff providing services 10. Reports of case conferences 11. Reports to physicians, following reporting guidelines 12. Signed release of information and other PHI documents 13. Admission, discharge from Hospital or other institutions 14. If applicable name of power of attorney, and/or healthcare power of attorney 15. Patient/family response to care, service provided 16. Termination summary including the date of first and last visit, the reason for termination of service, an evaluation of established goals at time of termination, the condition of the patient on discharge and the disposition of the patient. 17. Our Agency use paper/electronic medical record combination 18. Statement of Patient’s Rights 19. Advance Directives information if applicable Safety implementation of Electronic Medical Records (EMR) due to privacy and security risks are a concern due to hackers, identity theft, unauthorized access and corruption (alteration) of patient data, making EMRs available to far-flung health care providers necessarily makes them more accessible to Home Health Agency - - Skilled Professional Services C-18