9005 - Client record policy

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					    SUBJECT:         CLIENT RECORD POLICY                                  REFERENCE #9005
                                                                           PAGE: 1
    DEPARTMENT: DURABLE & HOME MEDICAL EQUIPMENT                             OF: 6
    APPROVED BY:                                                           REVISED:


        A client record shall be established and maintained to document the equipment or services
         provided to each client receiving rental equipment, respiratory care equipment or high-tech
         equipment. The record promotes continuity of care between the various disciplines of
         __________________ and enhances the interdisciplinary approach to providing client care

        The client record is maintained by __________________, who is directly responsible for
         billing. Client information shall be recorded on forms approved by senior management.
         Only commonly used and accepted abbreviations (refer to Approved Symbols and
         Abbreviations) are acceptable for recording practices.

        The client record shall be initiated at the time of the predischarge or set-up visit.


        A standardized format shall be used for documenting client record information. All client
         record information from internal and/or outside sources shall be routinely assembled in a
         timely manner. The client’s record shall contain data which includes, but is not necessarily
         limited to:

                 Full name, address, social security number, date of birth and telephone number of

                 Name and title of the person making the referral

                 Name and telephone number of the family member or significant other to be
                  contacted in an emergency

                 Physician’s prescription and current plan of care (equipment and service orders
                  including the type of frequency of services to be provided, the supplies and
                  equipment needed and therapeutic parameters for equipment use) (refer to Plan of
                  Care policy)

                 Signed Authorization to Treat form, if applicable (refer to Authorization to Treat

© The Compliance Doctor, LLC
 SUBJECT:            CLIENT RECORD POLICY                                    REFERENCE #9005
                                                                             PAGE: 2
 DEPARTMENT: DURABLE & HOME MEDICAL EQUIPMENT                                  OF: 6
 APPROVED BY:                                                                REVISED:

                 Signed invoice including company’s terms and conditions of rentals and sales

                 Documentation of receipt of Client Bill of Rights and Responsibilities

                 Findings of initial assessment and reassessments (as appropriate)

                 Notations regarding follow-up care (include date, staff person and description of
                  service which was provided)

                 Notations regarding all relevant client communications (letters, phone calls, in-house

                 Client’s activity restrictions or functional limitations (as appropriate to provide home
                  medical equipment)

                 Description of any safety measures required to protect the client from injury

                 Notations on the suitability or adaptability of the home for the provision of the
                  planned care or service

                 Changes in client’s condition related to provided service

                 Identity of other individuals and companies known to be involved in client care or

                 Instructions given to client, if he/she was discharged by __________________

                 Lab data, relevant test results, client history, transfer forms, etc. (as appropriate)

                 Medication profile, if appropriate

                 Height and weight, as appropriate

                 Information on client allergies, if appropriate

                 “DO NOT RESUSCITATE” orders, if any are documented and signed by client’s
                  physician in accordance with applicable law and regulations

© The Compliance Doctor, LLC
    SUBJECT:          CLIENT RECORD POLICY                                    REFERENCE #9005
                                                                              PAGE: 3
    DEPARTMENT: DURABLE & HOME MEDICAL EQUIPMENT                                OF: 6
    APPROVED BY:                                                              REVISED:


        The client record shall be maintained for the current year plus five (5) years following the
         year services were provided. The exception would be the case of a minor, in which case
         the record will be retained five (5) years after the minor turns 18, even if this exceeds
         normal retention. The records must be maintained even if __________________ ceases
         to operate. (May vary from state to state.)

        In some states, the law may require longer record retention. The more stringent restraint
         or obligation shall supersede.

        Additionally, __________________ shall keep all records of cases involved in litigation
         until the case is concluded, even if it goes beyond the time period prescribed by law.


        Supervision of client records shall be assigned to a specific employee. The employee shall
         assure adherence to the following:

                 Access:

                          Client records shall be stored in a secure area with access by authorized
                           client care and clerical staff only. Persons (company employees or
                           individuals under contract) involved with the client’s care, management, staff
                           and others responsible for processing financial claims have a legal right to
                           client information, although no
Description: medicare regulations for dme and hme companies require this policy if it is applicable to the types of services your dme provides, we make this easy for you with just a small amount of customization, you too will meet the requirements of the federal regulations. this policy is updated to the newest 2010 standards.
PARTNER Compliance  Doctor
THE COMPLIANCE DOCTOR, LLC is a consulting firm that offers services to assist health care professionals at the task(s) of state licensing, National Accreditation, as well as Medicare Certifications in any outpatient, ambulatory type of business. We assist the client by providing them leadership and consultation along the labored process of the regulatory world in health care. There is never a job too small, nor too big, we can handle them all.