Record of Care, Treatment, and Services-Policy and Procedure Template

Updated: Feb 25

__________________ Record of Care, Treatment, and Services" comprises of all data and information gathered about our patients; which functions as a historical record of their episodes of care, as well as a method of communication between practitioners and staff who facilitate the continuity of care and aid in clinical decision making.

General Information:

_____________________________ clinical record include the following:

Information needed to support the patient's diagnosis and condition;

Information needed to justify the patient's care, treatment, or services;

Information that documents the course and result of the patient's care, treatment, or services

Information about the patient's care, treatment, or services that promote continuity of care among providers.

Thus, the clinical record shall include the following demographic information:

The patient's name, address, phone number, and date of birth and the name of any legally authorized representative

The patient's sex, height, and weight

The legal status of any patient receiving behavioral health care services The patient's language and communication needs (if the patient is a minor, is incapacitated, or has a designated advocate, the communication needs of the parent of legal guardian, surrogate decision-maker, or legally authorized representative are documented in the clinical record.)

The clinical records shall include the following clinical information, as appropriate:

A medical history and physical examination completed and authenticated no more than thirty (30) days before or 72 hours after registration, but prior to surgery or a procedure requiring anesthesia services, except in the cases of emergencies.

An updated examination of the patient, including any changes in the patient's condition, when the medical history and physical examination are completed with thirty (30) days before registration. Documentation of the updated examination shall be recorded in the patient's clinical record within 72 hours after registration, but prior to surgery or a procedure requiring anesthesia services, except in the case of emergencies.

The patient's initial diagnosis, diagnostic impression (s), or condition(s)

Any findings of assessment and reassessments

Any allergies to food

Any allergies to medications

Any conclusion or impressions drawn from the patient's medical history and physical examination

Any diagnosis or conditions established during the patient course of care, treatment, or service

Any consultation reports

Any progress notes

Any medications ordered or prescribed

Any medication administered, including the strength, dose, route, date and time of administration

Any access site for medication, administration devices used, and rate of administration

The patient's response to any medication

Any adverse drug reactions

Plans for care and any revisions to the plan for care

Orders for diagnostic and therapeutic tests and procedures and their results

The clinical record shall include the following additional information, as need to provide care, treatment, or services:

Any advance directives

Any informed consent

Any documentation of clinical research interventions distinct from entries related to regular patient care, treatment, or services

Any records of communication with the patient, such as telephone calls or email Any referral or communication made to internal or external care providers and community agencies

Any patient-generated information

The clinical record of a patient who received urgent or immediate care, treatment, or services shall include the following:

The time and means of arrival

Indication that the patient left against medical advice, when applicable

Conclusions reached at the termination of car, treatment, or services, including the patient's final disposition, condition, and instructions given for follow- up care, treatment or services.

__________________________________ maintain complete and accurate clinical records; and all entries are dated.

____________________________________ reviews its clinical records to confirm that the required information is present, accurate, legible, authenticated, and complete on time, concurrently.

________________________ licensed care providers only shall be authorized to receive and record verbal orders, in accordance with law and regulation. Documentation of verbal orders shall include the date and the names of the authorized licensed care practitioners who gave, received, recorded and implemented the orders. Verbal orders shall be authenticated within 72 hours.

Transcribed information introduced in the clinical record shall be authenticated by the authenticated by the author.

PROCEDURE:

_________________________ is currently using ___EHR/or EDR Name____ as its Electronic Health and/or Dental Record system.

Documentation may be performed by ________________Authorized Care Practitioners.

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