Clinical records of present and past findings are maintained for every home health patient. The specific standards regarding clinical records for home health patients have been impacted by the recently introduced Conditions of Participation (CoPs). The updated CoPs include new as well as amended standards dealing with clinical records. Section 484.110 specifically outlines five specific standards, which are listed below in further detail:
Contents of Clinical Records
This newly introduced standard takes into account a variety of patient information. It includes contact information for the patient, the patient’s representative (if any), and the patient’s primary caregiver(s). In addition, it contains the contact information for the primary care practitioner or other health care professionals who will be responsible for providing care and services to the patient after discharge from the home health agency (HHA). A completed discharge summary or completed transfer summary is included in this standard. A completed discharge summary 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 home health agency (if any) within five business days of the patient’s discharge. If the patient’s care will be continued immediately in a home health care facility, then a completed transfer summary should be sent within two business days of a planned transfer. Finally, if the patient is still receiving care in a health care facility at the time when the home health agency becomes aware of the transfer then a completed transfer summary should be sent within two business days of becoming aware of an unplanned transfer.
The next standard deals with authentication and the different approved ways. According to this standard, it is key that all entries 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.
Retention of Records
According to this standard, clinical records must be retained for a minimum of five years after the patient has been discharged. However, state laws may even stipulate a longer period of time. Even if you discontinue operation of your home health agency, your policies must include information regarding the retention of your clinical records. You must inform your state agency where your clinical records will be maintained.
Protection of Records
It is critical that the information and contents contained in your clinical records be safeguarded against loss or unauthorized use. The rules that HHAs must be in compliance with are set out at 45 CFR parts 160 and 164.
Retrieval of Clinical Records
The final standard deals with the retrieval of a patient’s records. The timing of retrieval has been revised. Now whether hard copy or electronic form, a patient must have access to his/her clinical record within four business days or when the next home visit occurs, depending upon which comes first. It must be provided free of charge.
Just One Section of the CoPs Complexity
Clinical records standards may be a small sub-set of the new CoPs, but they are very specific. It is critical that they are followed accordingly. Also, it is imperative that your entire staff is well-informed not only about the standards affecting clinical records, but about every standard covered in the new Conditions of Participation. To help ensure your team is ready by the January 2018 implementation date we have developed a variety of education options. First, we offer an in-depth four-part CoPs webinar series available on DVD. Your team can view them at their convenience. Second, we offer onsite training if your team prefers a more interactive approach. If you would like more information about either training option, please feel free to contact us at [email protected] or 314-952-8392.