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Clinical Records

The clinical record contains pertinent past and current findings in accordance with accepted professional standards. A clinically signed and dated note, written the day service is provided, is completed for each visit and required to complete periodic progress notes that summarize the patient's progress over a period of time. These are incorporated into the clinical record along with copies of summary reports sent to the physician and a discharge summary. Home health agencies must have policies designed to protect clinical record information from loss or unauthorized disclosure.

There are two types of clinical record reviews required as part of the overall evaluation of the home health agency. Appropriate health professionals representing at least the scope of the program, must review a sample of both active and closed records to assure that established policies are followed in providing services. This review for appropriateness of services must be done at least quarterly. A second requirement mandates a continuing review of clinical records called Recertification for each 60-day period to determine adequacy of the plan of treatment and appropriateness of continuation of care.

The home health Agency Administrator is responsible for assuring that the agency conforms to all state and federal rules and regulations that apply to home health agencies. Each home health employee must be familiar with her own agency's policies and procedures and comply with them at all times.


- 3HC -
2402 Wayne Memorial Drive
Goldsboro, NC 27534
919-735-1387
info@3hc.org

 

© Copyright 2001-2007, 2008
Home Health and Hospice Care, Inc.; 2402 Wayne Memorial Drive; Goldsboro, NC 27534; 919-735-1387
For more information, please email 3HC at: info@3hc.org


 

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