Maintenance: A medical record shall be maintained for every individual who is evaluated or treated in a hospital, clinic, or physician's office; the record may consist of electronic and/or paper documentation and is confidential and protected from unauthorized disclosure.
Content: Medical record content must meet state, federal, and accreditation requirements (including Medicare Conditions of Participation 42 CFR 482.24) and must identify the patient and support the diagnosis; entries must justify care, treatment, and services, document course and results, and promote continuity of care.
Entry Requirements: All entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for the service or evaluation; all documentation must be identified with the patient's full name and unique medical record number.
Timeliness: Entries should be made as soon as possible after the care or service; operative and procedure reports must be completed immediately after surgery; the record must be completed promptly after discharge but no later than 30 days following discharge.
Authentication of Verbal Orders: All verbal orders must be authenticated in accordance with federal and state law; if state law does not specify a timeframe, verbal orders must be authenticated within 48 hours.
Form, Indexing and Security: Providers must have systems for coding and indexing records and author identification to ensure integrity of authentication; records must be retained in original or legally reproduced form for at least 10 years and maintained in a safe, secure area with safeguards against loss, destruction, and tampering.
Corrections and Amendments: Original entries must not be obliterated. Corrections must indicate the reason, be dated and signed. For paper records, draw a line through the incorrect entry and annotate with date, reason, and signature; for electronic records, correct via an addendum that includes corrected information, identity of the individual, date, and electronic signature. Late entries must be identified as such, dated with the current date/time, and signed.
Restriction on Post-audit Editing: Changes to medical records will not be accepted for the purpose of altering reimbursement when made in response to a medical record audit.