|
COMPLETION OF MEDICAL RECORDS
PURPOSE:
To ensure that all Medical Records are completed within ten days of
death or discharge.
DEFINITION:
A "Complete Medical Record" is one in which all error or deficiencies
have been corrected; a discharge summary has been completed by all
departments involved in resident care; the correct ICD-9-CM code has
been assigned to the final diagnosis and recorded in the Disease Index;
and the record is properly secured and filed.
PROCEDURE:
The following list outlines the steps for prompt completion of Medical
Records.
A. Remove the chart from the nursing unit and obtain all purged portions
of the record from the medical record files.
B. Use the "Medical Records Discharge Check List" to assemble the chart
and document deficiencies.
C. Notify departments of charting deficiencies and discharge summaries
that they need to complete.
D. A memo of record is written in all charts that contain unsigned
documents to verify that staff are no longer employed at this facility
and, as such, can not complete their portion of the medical record.
E. Assign the correct ICD-9-CM code to the final diagnosis and record it
in the Disease Index.
F. All items under "Discharge Information" on the bottom portion of the
Admission Record are to be completed except Length of Stay and Total
Days Stay.
G. Sign and date the "Medical Records Discharge Check List" to verify
completeness.
H. Properly secure and file the medical record.
I. All photocopies of records pertaining to resident care during their
stay at another facility are to be destroyed.
MEDICAL RECORDS - 35-03-011
« Medical Records Table
of Contents |