Appalachian District Health Department
Policy and Procedure Policy Name Management Operations Policies Policy Topic Patient Records’ Management
Section 200
Approved Date: 11-10-89
Chapter 204
Revision Date: 12-15-14
Purpose: It is the purpose of Appalachian District Health Department to ensure confidentiality and safeguard against loss of protected health information. Policy: It is the policy of Appalachian District Health Department to provide a medical record for each client who obtains clinical services, which will be maintained in a secure environment. Procedure: 1. Maintenance and retention of clinical records: a. Retention of files is in accordance with State Retention of Records schedule. Purging of information contained in each record is done as needed. b. Medical records must be complete, legible, and accurate. c. Abbreviations are agency approved. d. All encounters are dated and electronically signed by the clinician or provider. e. Records are readily accessible and systematically organized to facilitate prompt retrieval of information. f. All records are to remain confidential and are safe guarded against loss or use by unauthorized persons. Records are to be handled only in areas supervised by authorized personnel. During client clinic visits, records will be handled in a manner so as not to expose client information to others. g. The transfer of medical records to other providers will be expedited upon the patient’s request. h. All paper records are to be returned to the records room at the end of each day or when not in use. These files are secured by lock. i. If necessary, paper charts / records taken out of the department for audit purposes, court subpoena or other necessary reasons, will be transported in a locked container and kept in possession of employee responsible until returned to the records room in the agency. 2.
Files and Filing Procedures Patients are assigned a medical record number upon registration for services. The information contained in the medical record will be organized as follows: Identifying information, in the form of a patient label, will be placed on pages that contain medical information/patient information, before being uploaded into patient’s chart.
1|Management Operations Policies – Patient Records’ Management
Appalachian District Health Department
Policy and Procedure Policy Name Management Operations Policies Policy Topic Patient Records’ Management
Section 200
Approved Date: 11-10-89
Chapter 577
Revision Date: 12-15-14
3. Signature Procedure: Upon making an entry into a chart, signatures must be written with the first initial, last name and discipline or title. A list of signatures and initials will be kept on file with the nursing supervisor. A list of signatures for testing personnel will be kept on file in the laboratory manual. 4. Abbreviations: Abbreviations used in medical charts will be listed on an approved Agency Abbreviation list. The abbreviations on the approved list are the only abbreviations to be used. This will be shared with all clinic staff. This list will be reviewed and updated annually by staff. 5. Documentation of services: a. Documentation of service provided will be completed in the patients chart or master card either immediately at time of service or within 72 hours of time service is performed. If staff is unable to complete documentation during this time frame, the immediate supervisor will be informed so scheduling changes can be made to allow completion of documentation. b. Documentation will demonstrate that services were provided according to program requirements as outlined in either, DMA guidance, contract addenda or local agency policy, including source of order (standing orders, verbal orders, telephone orders, faxed orders, etc). All patient encounters (including telephone and face-to-face conversations) will be documented in the patient medical record. c. When an entry needs to be made more than 72 hours after the service was performed or after a record has been “closed”, make an “Addendum” to the encounter in the electronic medical record, date it for the day you are adding the documentation and label the entry “Late Entry for (the date it should have been written)”.
6.
Records must contain sufficient information to identify the client, indicate contact information, justify clinical diagnosis, and warrant the treatment and end results. The required content includes: a. Personal data b. Scheduled visits c. Medical history, physical exam, clinical findings, diagnostic/laboratory orders, results, and treatment d. Documentation of continuing care, referral and follow-up
2|Management Operations Policies – Patient Records’ Management
Appalachian District Health Department
Policy and Procedure Policy Name Management Operations Policies Policy Topic Patient Records’ Management
e. f. g. h.
Section 200
Approved Date: 11-10-89
Chapter 577
Revision Date: 12-15-14
Informed consent(s) Refusal of services Allergies and drug reactions Medical record allows for entries by counseling and social service staff
7. Confidentiality and Release of Records: a. A confidentiality assurance statement will be in each record. b. HIV information is handled according to State law. c. A written consent of the client is required for release of personally identifiable information, except as may be necessary to provide services to the client or as requir4ed by law with appropriate safeguards for confidentiality. See chapter 800 HIPAA Policies. 8. Billing for services: Billing for any service will not be submitted for payment until the documentation is complete in the client record. 9. Document Shredding: Any documents which contain financial or confidential information about the health department or patients should be disposed of by shredding. 10. Handling and Storage of Paper Medical records: Staff who are involved in the care of the client may access medical records from the front office medical records designated area by removing the record from the filing shelf and placing a sign out card that indicates where the record will be located for which program and by who. Charts that have been removed from the medical records area for service or follow up are returned to the front office medical records area at the end of each day where they are locked securely in that medical records area in each department. Only staff who are involved in providing services to clients are allowed in the medical records area. All staff signs a confidential agency statement and are informed of HIPAA policies.
3|Management Operations Policies – Patient Records’ Management
Appalachian District Health Department
Policy and Procedure Policy Name Management Operations Policies Policy Topic Patient Records’ Management
Section 200
Approved Date: 11-10-89
Chapter 577
Revision Date: 12-15-14
4|Management Operations Policies – Patient Records’ Management
