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Accreditation for Medicare Deemed Status
6. Clinical Records and Health Information Standards
6.H. Clinical records are consistent across records.
6.H.1. Entries include date and department
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6. Clinical Records and Health Information Standards
6.A. The ASC must maintain complete, comprehensive, and accurate medical records to ensure adequate patient care.
6.A. Resources
6.B. The ASC must develop and maintain a system for the proper collection, storage, and use of patient records.
6.B.1. Designated person in charge of clinical records
6.B.4. System is monitored
6.C. Written policies for clinical records are present.
6.C.1. Policies address security of information, including editing, deleting, and accessing
6.C.2. Policies address release of patient records
6.C.3. Policies address protection from damage or loss and back-up systems
6.C.4. Policies address deterring unauthorized access
6.C.6. Policies address retention of active records
6.D. Clinical records are maintained in a manner that facilitates the provision of safe care.
6.D.1. Records are organized in a consistent manner
6.D.3. Record entries are easily accessible to authorized personnel
6.D.5. Patients approve or refuse release of records
6.E. The ASC must comply with the Department's rules for the privacy and security of individually identifiable health information, as specified at 45 CFR Parts 160 and 164.
6.E. Resources
6.F. Except when otherwise required by law, any record that contains clinical, social, financial, or other data about a patient is treated as strictly confidential.
6.F.1. Policies require confidentiality of information
6.G. An individual clinical record is maintained for each person receiving care. Every record must be accurate, legible, and promptly completed. Medical records include at least the following items.
6.G.1. Each record includes patient identification
6.G.2. Each record includes an identification number
6.G.3. Each record includes patient gender
6.G.5. Each record includes entries related to anesthesia administration
6.G.6. Each record includes documentation of informed consent
6.H. Clinical records are consistent across records.
6.H.1. Entries include date and department
6.H.2. Entries include medical history and physical examination
6.H.3. Entries include preoperative diagnostic studies
6.H.4. Clinical records include findings and techniques of the surgery, including pathologist's report
6.H.5. Entries include changes in prescription and non-prescription medication with name and dosage
6.H.6. Entries include discharge diagnosis and instructions
6.H.7. Entries include signature or authentication of the health care professional
6.I. The presence or absence of allergies, sensitivities, and other reactions to drugs, materials, food, and environmental factors is recorded in a prominent and consistently defined location in all clinical records.
6.I.1. Clinical records document that the patient was asked about allergies and sensitivities at each encounter
6.I.2. Clinical records indicate that the patient was asked about other reactions at each encounter
6.I.4. Information from 6.I.1. and 6.I.2. is verified and updated at each patient encounter
6.J. Reports, histories and physicals, progress notes, and other patient information such as laboratory reports, x-ray readings, operative reports, and consultations, are reviewed and incorporated into the record, as required by the organization's policies.
6.J.2. Items incorporated into the clinical record
6.J.3. Date of entry of information is documented in the record
6.K. Clinical records document discussions with the patient concerning the necessity, appropriateness, and risks of the proposed care, surgery, or procedure, as well as discussions of treatment alternatives, as applicable.
6.K. Resources
6.M. Clinical records demonstrate that the organization ensures continuity of care for its patients.
6.M.2. Records include documentation of medical advice provided
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Element of Compliance
Entries include date and department
Documentation Required
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