Policy Manual sample

MDT Home Health Care Agency, Inc. signatures will be date-stamped. 10. The following have access to andmay also reviewmedical records: Medicare, Medicaid, third party payors, QAPI committee, other Agency’s Committee, accrediting organizations if applicable), authorized consultants, home care personnel and other relevant allied health care personnel. 11. All persons who have access to home care records and/or other patient information has the obligation to treat the information confidentially. 12. No correction fluid or tape will be used to correct errors. An error should be corrected by marking one line through the error and then dating and initialing the error. 13. Staff are encouraged to enter all relevant documents and entries into the medical record at the time that they are rendering the service. 14. Regardless of whether documentation submission originates from a paper or electronic record, corrections must follow the following principles: • Clearly and permanently identify any amendment, correction or delayed (late) entry as such. • Clearly indicate the date and author of any amendment, correction or delayed (late) entry. • Not delete but instead clearly identify all original content. 15. When correcting a paper medical record, these principles are usually accomplished by using a single line strike through so that the original content is still readable. The author of the alteration must sign and date the revision. Amendments or delayed (late) entries of paper records must be clearly signed and dated upon entry into the record. 16. Electronic health records containing amendments, corrections or delayed (late) entries must: • Distinctly identify any amendment, correction or delayed (late) entry. • Provide a reliable means to clearly identify the original content, the modified content and the date and author for each modification of the record. 17. The Agency protects the integrity of health information against: • Loss: records are not permitted to be removed from office except in response to law/regulation, court order or subpoena, or to safely approved storage. • Damage: records are stored in a manner to prevent water damage and decrease fire risk. • Unauthorized alteration by staff is grounds for immediate termination. • Unintentional changes and/or accidental destruction of information will be reported to the Director of Nursing, Clinical Manager immediately. • Intentional destruction is strictly prohibited by Agency, and is grounds for immediate termination and possible legal effects. Home Health Agency Bylaws H-12