Home Health and Hospice
Policy and Procedure Manual
Patient Clinical Records
Home Health and Hospice will establish and maintain a separate clinical record for every patient receiving Home Health
and/or Hospice service. The clinical records will be assembled in a systematic fashion allowing for easy access to this
information by the Home Health staff. The Secretary will establish and maintain the patient records. The Secretary and trained
staff members will file all documentation in the patient record every week according to a standardized format (see Sample
Chart).
Only Agency staff members will have access to the patient clinical records. Information from the patient clinical records
will only be disclosed as described in the Authorization for Treatment Acknowledgment of Rights and Responsibilities form,
unless the patient gives consent or in response to a valid subpoena or court order. The requesting party will reimburse Home
Health and Hospice for the usual and customary charges incurred in copying the records. Agency staff members may copy
parts of the patient’s clinical record as needed for the deliver of their care. Consent for release of medical records applies after
the patient’s death. Only those persons with legal authority to request copies of the patient's medical record may do so. This
includes persons who may be the trustee or executor of that person’s will but not someone who had power of attorney prior to
that person’s death. The power of attorney only applies while the person is alive.
The clinical records will be stored in a lockable filing cabinet, protected by staff members from any unauthorized access.
In addition, laptop computers and workstations will be password protected, each employee with their own password. If the
laptop or workstation is not in use, the employee will log out of the program to ensure patient confidentiality. In the event that
an employee, who has authorization to access any portion of computer leaves employment, their password will be deleted
from the database to prevent unauthorized access of patient or Agency information. In the event of a possible security breach,
a new password will be assigned to any or all appropriate employees. The Fiscal Manager will maintain the master password
list, assign or delete passwords as needed. The Office Manager and Secretary will have knowledge of and be able to access
the master password list if needed in absence of the Fiscal Manager. In the event of destruction of the clinical records,
constant data may be retrieved from the information management system. Constant data includes:
1.
2.
3.
Basic demographic information.
Most current HCFA-485 information.
Interim orders pertaining to the schedule.
Entries will be made, signed and dated by the person providing care to the patient or patient’s family on the appropriate
forms. The documentation in the clinical record will be accurate and reflect the physical condition of the patient, the
psychosocial status of the patient and family, and the care provided from admission through discharge. All pertinent
information about the patient and the patient’s family will be filed in the clinical record.
Each patient’s clinical record will contain at least, but not limited to, the following:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
HCFA-485 form.
Initial and subsequential assessments by all disciplines.
Authorization for treatment and acknowledgment of rights.
Release of information form.
Identification data.
Pertinent medical history.
Home Health Aide assignment sheet.
Complete documentation of services and events, including, but not limited to, evaluations, treatments and progress
Interim orders.
Laboratory result sheets
Discharge summaries.
Med flow sheet.
Progress notes.
60-day physician summaries.
Advanced directive information.
OASIS documents
Home Health and Hospice
Policy and Procedure Manual
Patient Clinical Records (cont.)
All entries in the clinical record will be legible and accurate. Errors will be corrected by the following procedure:
1.
2.
3.
4.
A line is drawn through the error.
The word “error” is written beside the drawn line.
The person correcting the error initials and dates the correction.
The correction is documented on the same form as the error.
*Note: White-out or any other correction fluid, tape or other similar materials may not be used to correct an error.
Only accepted abbreviations will be used in any documentation (see abbreviation list).
Patient records that have become full, limiting the visibility of the patient’s name while the file is in the normally filed
position will be thinned. The Chart Coordinator and/or the Agency secretaries will thin the patient’s clinical record, leaving at
least, but not limited to, the following in the clinical record:
1.
2.
3.
4.
Paperwork that is between two (2) months and current:
a)
All clinical visit reports for all disciplines.
b)
Laboratory result sheets.
c)
HCFA-485 forms.
d)
Interim orders.
e)
Progress notes.
f)
60-day physician summaries
g)
OASIS documents
All admission paperwork.
Discharge summary from the patient’s most recent hospitalization.
Any communication sheets.
The clinical records will be retained for at least six (6) years in a protected area to safeguard against loss, destruction or
unauthorized access. After six (6) years, or when it is determined that the record(s) are no longer necessary to retain, these
records will be destroyed in such a manner as to maintain confidentiality. Appropriate methods of destruction will be (but
are not limited to) shredding or storing in a sealed container until the Hazardous Waste Disposal representative receives it for
incineration. Terms of the agreement with the Hazardous Waste Disposal Company will include protection of confidentiality
of materials. Records of minors will be retained until the age of majority plus an additional seven (7) years. Only the patient
or the patient’s officially appointed representative may request a copy of any portion of the patient’s medical record. Any
request for a copy of the patient’s medical record shall be in writing. The Agency shall charge the standard fee, which is
currently $15 plus $.25 per copied page.
The clinical records will be reviewed as part of the Continuous Quality Improvement program.
The final responsibility for the patient records will rest upon the Agency and the Agency’s governing body. Should the
Agency be dissolved, the State Department of Health will be notified of the date of the dissolution and the location of all
patient records.