Policy Manual sample

MDT Home Health Care Agency, Inc. (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. (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). 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 the world at large, our Agency use combination of electronic/paper medical records at this time. No information may be disclosed from the patient’s file without the written consent of the patient or the patient’s guardian. All information received by any employee, contractor, or AHCA employee regarding a patient of the Agency is confidential. Each home visit, treatment, or care/service is documented in the patient record and signed by the individual who provided the care/service. Signatures are legible, legal and include the proper designation of any credentials. If the patient transfers to another home health agency, a copy of his record must be transferred at his request. All clinical records contents (clinical notes, reports, assessments, etc) will be filed within 15 to 21 days, after received by the agency, in the individual client medical records, to allow QA staff complete/review the quality of the documentation provided for our field staff, and must be retained by the Agency for a period of five years following the termination of service (death/discharge). Clinical records shall be maintained for five (5) years, for all adults patients, minors clients records will be retained for a minimum of (5) five years after the age of majority is reached, Client records involved in litigation are retained until after settlement. Retained records can be stored as hard paper copy in authorized/secure storage, and must be retrievable for use during unannounced surveys. When comprehensive assessments are corrected, our Agency will maintains the original assessment as well as all subsequent corrected assessments. The following applies to signatures in the clinical record: Facsimile signatures: The plan of care or written order may be transmitted by facsimile machine, in CONFIDENTIAL manner, including a CONFIDENTIAL cover. The home health agency is not required to have the original signature on file. However, our agency is responsible for obtained original signatures if an issue surfaces that would require certification of an original signature. Our agency will not accept rubber stamps signatures for physicians to prevent fraud. Home Health Agency Policies A-47