POLICY

The clinical record serves as a basis for documentation of medical care rendered to the client and for communication between the physician, qualified referral sources and the personnel providing the services. The administration department maintains, at all times, the content add the clinical record presence or, at a minimum, an adequate picture of the care being given. In addition to serving as a basis for documentation of care rendered to clients, the clinical record provides evidence of the center's implementation of policies and procedures as they relate to client care.

 

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PROCEDURE

To ensure compliance with this policy the following sources of information will be audited no less than quarterly and reported to management at the client care committee meetings:

• three active and two discharged records;

• review with the staff policies and procedures regarding compliance, retention of records, and confidentiality of clinical records;

• HIPAA compliance.

 

 

STANDARD SUBSECTION (A): Protection of Clinical Record Information

POLICY

Google records are to be accessed by authorized personnel only. For release of any material not authorized by the law, the client's written consent is required.

 

PROCEDURE

All center personnel will be provided with levels of authority to access the clinical records. All employees are given a username and a default password. The password should be changed after the first logon by the individual employee. The new password is not to be shared with anyone in order to comply with HIPAA regulations. See attachments:

• Authorization for Request / Disclosure of Protected Health Information

• Employees Confidentiality Form

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STANDARD SUBSECTION (B & C): Content; Completion of Record and Centralization of Reports

POLICY

All records will contain the following data:

• Assessment of needs of the client, appropriate plan of care and the care and services furnished.

• Intake paperwork and consent forms

• medical history

• report a physical examination, if any

• observations and progress notes

• reports of treatments and clinical findings

• discharge summary, including final diagnosis(es) and prognosis

 

PROCEDURE FOR AUDITING RECORD COMPLIANCE

Examine three active and two discharged clinical records, selected on a random basis and not restricted to those of Medicare clients only, to ascertain whether the appropriate material as specified in §485.721 (B) is included.

 

The assessment of the needs and the client (initial evaluation and re-evaluations where appropriate), plan of care (including the types, amount, duration and frequency of services provided), identification data (name, address of client, and age), observation and progress notes, reports of treatments and clinical findings, and discharge summary should be contained in all clinical records. Documentation of communication efforts between professionals providing services should also be present. However, consent forms, medical history, and the physician’s physical examination may or may not appear in the clinical records. This information would need to appear only where relevancy to client treatment is shown. Where medical history does not appear in clinical records, it may not have been transmitted by the physician but, rather, may have been obtained from the client or family when the past and present history was relayed.

 

Have any pertinent information is noted in the clinical records, additional clinical record reviews should be undertaken to determine the prevalence of such omissions. Survey should stay on the record review form the clinical records reviewed and the number and types of deficits found in each. Where record reviews prompt questions concerning client care, the surveyor should request additional information and assistance from the appropriate personnel.

 

The discharge summary will include the date and reason for discharge, a brief summary of the current status of the client at the time of the discharge, and, where applicable, the provision for referral of the client to another source for continuing care.

 

Progress notes should be updated in the client's clinical record no less than every 30 calendar days.

 

All information appearing in the clinical record is to be dated appropriately, finalized within the appropriate time allowed and contain a start and stop time of the therapy services.

Regardless of whether the clinic provides services through its own employees or through an arrangement with others, all materials that are pertinent to the client's treatment are to be part of the clinical record, which is to be maintained in the company’s Electronic Medical Record (EMR), Raintree. All clinical information pertaining to a client is centralized and the client’s clinical record

 

 

STANDARD SUBSECTION (D): Retention and Preservation

POLICY

The clinic policy pertaining to retention and preservation of clinical records shall retain clinical record seven years or until clients are 21 years of age, as in compliance with state and federal laws. Any event the clinic ceases to function, it is the policy of the clinic that all records will continue to be stored online, through the EMR program until the client becomes 21 years of age. After the client reaches 21 years of age, the files will be deleted.

 

 

STANDARD SUBSECTION (E): Indexes

POLICY

Clinical records are alphabetized by the name of quiet, in raintree EMR, two facilitate acquisition of statistical medical information and retrieval of records for research or administrative action.

 

 

STANDARD SUBSECTION (F): Location and Facilities

POLICY

The clinical records are to be easily retrievable, through computer access and available to all professional staff members of the clinic and other authorized individuals. the clinical records will also be stored according to HIPAA regulatory standards that are in effect as of April 16, 2003. All files must be available in the event of an audit by state or federal regulatory regulators. Files must be available for prompt retrieval via electronic format.

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CREATED:  04-01-2012

REVISED: October 2020​

Form CMS-1893 (12/08):  42 CFR §485.721;

AAAASF Medicare RA/OPT (V. 3.0) Section 15; Sub-Section J