Home Health & Hospice Week

Make sure your records contain these 6 proposed elements.

How robust are your clinical records? It may matter more on your next survey.

“The clinical record requirements are more detailed” in the newly proposed Conditions of Par-ticipation changes, points out attorney Robert Mar-kette Jr. with Hall Render in Indianapolis.

Specifically, “we propose to add the requirement that the information contained in the clinical record would need to be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician who is responsible for the home health plan of care and appropriate HHA staff,” the Centers for Medicare & Medicaid Services says in the rule published in the Oct. 9 Federal Register. “The clinical record would be required to exhibit consistency between the diagnosed condition, the plan of care, and the actual care furnished to the patient. Consistency would be reflected in the appropriate link between patient assessment information and the services and treatments ordered and furnished in the plan of care. In light of the decentralized nature of HHAs (that is, patient care is not furnished in a single location), we believe that members of the interdisciplinary team must have access to patient information in order to provide quality services.”

Under the new COPs, CMS says “we would require that the clinical record include”:

(1) the patient’s current comprehensive as-sessment, including all of the assessments from the most recent home health admission, clinical visit notes, and individualized plans of care;

(2) all interventions, including medication administration, treatments, services, and responses to those interventions, which would be dated and timed in accordance with the requirements of proposed §484.110(b);

(3) goals in the patient’s plan of care and the progress toward achieving the goals;

(4) contact information for the patient and representative (if any);

(5) contact information for the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA; and

(6) a discharge or transfer summary note that would be sent to the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA within 7 calendar days, or, if the patient is discharged to a facility for further care, to the receiving facility within 2 calendar days of the patient’s discharge or transfer. (CMS requests comments on these timeframes specifically.)