Policy Manual sample

MDT Home Health Care Agency, Inc. POLICY ON CLINICAL RECORD KEEPING In accordance with the regulations ( § 484.110), it is the policy of our Agency that quality clinical records shall be maintained on all patients. A separate patient record is maintained for each patient. The patient record contains pertinent past and current findings in accordance with accepted professional standards. Accordingly, skilled nurses/therapists shall maintain and accurately fill out the respective clinical forms on each patient, as follows: · Identification data · Names of family/legal guardian/emergency contact · Name of primary caregiver(s) · Source of referral · Name of physician responsible for care · Diagnosis · Physician’s orders that include medications, dietary, treatment and activity orders · Signed release of information and other documents for Protected Health Information · Admission and informed consent documents · Assessment of the home; if applicable · Initial assessments (OASIS if applicable) · Ongoing assessments; if applicable (OASIS if applicable) · Signed notice of receipt of Patient Rights and Responsibilities · Advance Directives; if applicable · Admission and discharge dates from a hospital or other institution; if applicable · Names of power of attorney and/or healthcare power of attorney; if applicable · Evidence of coordination of care/service provided by the organization with others who may be providing care/service; if applicable · Signed and dated clinical and clinical notes · Copies of summary reports sent to physicians; if applicable · Patient/family response to care/service provided · A discharge summary; if applicable · Initial plan of care · Updated plan of care (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. Home Health Agency Policies A-46