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PURGING ACTIVE MEDICAL RECORDS
PURPOSE:
To reduce the number of inactive pages in a Resident's Medical Record
within time periods designated by the New Jersey Department of Health
and U.S. Veterans Affairs Standards.
DEFINITION:
"Purging" is the removal of pages from a Medical Record that are no
longer actively needed by staff in providing care to residents.
PROCEDURE:
The following list of forms may be deleted from active charts after the
amount of time specified by each item. Individual charts are labeled
indicating the name of the resident; the date pages were deleted from
the chart; and the signature and title of the person who purged the
Medical Record.
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History and Physical:
Admission H&P and the results of the most recent examination
must remain in the chart.
Medical Plan of Care & Recertification:
Initials certification and medical plan of care, and
recertification for the last six (6) months must remain in the
chart.
Physicians' Orders:
Admission order and all orders for the last six (6) months
must remain in the chart.
Physician Progress Notes:
Admission note and all notes for the last six (6) months must
remain in the chart.
Dietary:
Initial assessment and all notes for the last six (6) months
must remain in the chart.
Activities:
Initial evaluation and all notes for the last six (6) months
must remain in the chart.
Nurses Notes:
Initial note and all notes for the last three (3) months
must remain in the chart.
Medication & Treatment:
Initial records and records of all medications and Sheets:
treatments that have been provided during the last six (6)
months must remain in the chart.
Laboratory, Radiologic and Diagnostic Tests:
Records of all laboratory, radiologic and other diagnostic tests
for the last six (6) months must remain in the chart.
Rehabilitation:
Initial evaluation and all notes for the last six (6) months
must remain in the chart.
Social Services:
Initial evaluation and all notes for the last six (6) months
must remain in the chart.
Transfer Forms:
Records of all transfers to and from the facility that
occurred in the last six (6) months must remain in the chart. |
MEDICAL RECORDS - 35-03-012
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