PROFESSIONAL PRACTICE STANDARDS FOR LONG TERM CARE

Federal Requirements for Long Term Care Facilities require that:

"The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete, accurately documented, readily accessible and systematically organized."

Therefore, the Professional Practice Standards for Long Term Care are used to evaluate individual areas of the health record, serve as a guideline for content development of health record policies and procedures, provide data for inservice programs, establish confidentiality of the health record and are to be used as a tool in the contemplation of procedural changes for cost-effective and more efficient operations.

The Professional Practice Standards for Long Term Care are:

CONTENT OF THE HEALTH RECORD - PRACTICE STANDARD I

- INITIATE, FACILITATE AND PROMOTE THE ATTAINMENT OF HIGH QUALITY CONTENT OF HEALTH RECORDS IN ACCORDANCE WITH FACILITY'S POLICIES. RATIONALE: Health care delivery, planning, research and other administrative activities and dependent upon health care data supported by timely and adequate documentation of quality patient care.

HEALTH CARE DATA - PRACTICE STANDARD II

- DESIGN AND MANAGE HEALTH CARE INFORMATION WHICH IS USED IN THE EFFECTIVE AND EFFICIENT MANAGEMENT OF THE HEALTH CARE DELIVERY SYSTEM. RATIONALE: Reliable and valid data require accurate collection and processing systems.

CONFIDENTIALITY - PRACTICE STANDARD III

UPHOLD THE CONFIDENTIALITY OF HEALTH RECORD INFORMATION AND PROTECT HE INDIVIDUAL'S RIGHT TO PRIVACY IN THE COLLECTION AND DISCLOSURE OF PERSONALLY IDENTIFIABLE MEDICAL AND SOCIAL INFORMATION. RATIONALE: Medical and social information, documented in the health record to facilitate and evaluate patient's care, is highly personal and sensitive. Because it is the patient's information, it may be disclosed only as the patient authorized, or as required by statute.

RETENTION AND RETRIEVAL - PRACTICE STANDARD IV

- PROVIDE SYSTEMS FOR HEALTH DATA/RECORD RETRIEVAL AND RETENTION WHICH MEET THE NEEDS OF HEALTH CARE CONSUMERS, FACILITIES AND PROVIDERS. RATIONAL: Since confidential health data are used in continuing patient care as well as for administrative, legal, quality assurance, research and educational purposes, a system must be available to assure easy retrievability, yet maintain security and control of the data.

MANAGEMENT AND SUPERVISION - PRACTICE STANDARD V

- UTILIZE EFFECTIVELY THE AVAILABLE RESOURCES IN PERFORMING MANAGEMENT AND SUPERVISORY FUNCTIONS. RATIONAL: Health record management requires the skill to plan, organize and control the various functions in a cost effective manner to facilitate achievement of the facility's goal.

EXTERNAL REQUIREMENTS AND STANDARDS - PRACTICE STANDARD VI

- ASSURES CONFORMANCE TO STATUTES, REGULATIONS AND STANDARDS FROM EXTERNAL AGENCIES AS THEY APPLY TO HEALTH RECORD INFORMATION AND RELATED DOCUMENTATION. RATIONALE: External agencies mandate requirements which control the licensure, certification accreditation status of the health care facility.

MEDICAL RECORDS - 35-02-002

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