Keeping Records Systematic, Hydramatic and Grease Lightning
SystematicIn accordance with the Centers for Medicare and Medicaid Services (CMS) Federal Regulation 514, medical records must be maintained for every resident in a senior or long-term care facility. Its critical each facility have formalized systems in place that provide complete, accurately documented, systematically organized and readily accessible records. The medical records in a long-term care facility should reflect and maintain the multi-disciplinary approach to assessment, care planning and care delivery. The regulation futher states a clinical record must contain an accurate and functional representation of the actual experience of the individual at the facility.
HydramaticJust like an automatic transmission helps to run a car, an organized filing system for records is also needed to keep a health care facility in gear, meaning all records should have an established chart order or order of filing that is followed. This process should be kept in the record to direct staff to the proper location of forms. If portions of the record will be retained in an electronic medical record system, policies should differentiate between paper-based and electronic.
Processing discharge records is an important aspect in management of record systems. Its the responsibility of the long-term care provider to protect the records from loss, destruction and unauthorized use. The storage methods and systems must be secure and protect the confidentiality of resident information, and the storage space must be adequate to protect the physical integrity of the record.
Keep Talkin Woah Keep TalkinCMS Federal Regulation 515 requires clinical records be maintained for 5 years from the date of discharge or death of resident when there is no other requirement by state law, or for a minor, 3 years after a resident reaches legal age as defined by state law. For Medicare residents, 5 years must be maintained after the month the cost report is filed (HIM 12 Medicare Manual). Every facility should define in policy their specific retention period not to be less than the period defined by state or federal law.
Grease LightningAs more personal information is accumulated electronically, maintaining clinical records that are accurate and systematically organized will provide doctors, nurses, consultants and other clinical staff information to make better decisions about a patients health care needs and may assist in reducing potential claims.
Did we get the song stuck in your head yet?
ABOUT THE AUTHOR