California
Medical Record Service.
22 CCR 74888
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22 CCR 74888
22 CCR 74888
§ 74888. Medical Record Service.
(a)
A hospice must establish and maintain a patient medical record system to ensure that the care and services provided to each patient are completely and accurately documented, readily accessible, and systematically organized to facilitate the compilation and retrieval of information.
(b)
A hospice's medical record service must include, but is not limited to:
(1)
Use of a record maintenance system that protects the security of medical record entries and requires authentication of documentation.
(2)
Develop, implement, and maintain documented policies and procedures for information governance that the governing body must approve.
(c)
A hospice's medical records service must develop, implement, and maintain documented policies and procedures for the following activities pertaining to patient medical records:
(1)
The retrieval of medical information.
(2)
Reconciliation. For the purpose of this section, “reconciliation” means the process of ensuring that a hospice generates a complete and accurate medical record for a patient upon discharge.
(3)
Deficiency analysis. For the purpose of this section, “deficiency analysis” means the process for detecting absent or missing medical information in a patient's medical record.
(4)
Coding.
(5)
Filing.
(6)
Indexing.
(7)
Quality and content control.
(8)
Release of information.
(d)
A hospice must ensure that all patient medical records are accessible to authorized individuals 24 hours a day, seven days a week.
(e)
Patient medical records must be accessible for the following reasons which include, but are not limited to:
(1)
Patient care needs.
(2)
Release of medical information requests.
(3)
Patient requests to amend or correct their record.
(4)
Department surveys or other requests from the Department.
(f)
Pursuant to subdivision (e)(3), a hospice must comply with a patient's right to examine, obtain, and request corrections or amendments to their medical record, pursuant to Health and Safety Code sections 123110 and 123111, and Title 45 of the Code of Federal Regulations sections 164.524 and 164.526.
(1)
A hospice must provide a patient a copy of their medical record within 15 days after receiving a release of medical information request, pursuant to Health and Safety Code section 123110(b).
(2)
A hospice must develop, implement, and maintain documented policies and procedures for the following:
(A)
How and when the hospice must provide notification to a patient if a request for correction or amendment to a patient's medical record was received.
(B)
How to determine if a patient's request to correct or amend their medical record should be approved or denied.
(C)
How and when the hospice must provide notification if a request for correction or amendment to a patient's medical record was approved or denied.
(3)
Documentation showing that a patient made a request, and whether the request was approved or denied, must be included in the patient's medical record. If a request was denied by the hospice, documentation must include a written justification for denial.
(g)
A hospice must develop, implement, and maintain documented policies and procedures in accordance with the federal Health Insurance Portability and Accountability Act (HIPAA) and California's Confidentiality of Medical Information Act (CMIA) laws for the planned disposal and destruction of patient medical records after the required retention period pursuant to section 74896(b).
(h)
A hospice must obtain a certificate of destruction from a shredding or destruction company if the hospice hires a company for the disposal of patient medical records. The contracted shredding or destruction company must be compliant with the federal Health Insurance Portability and Accountability Act (HIPAA).
(i)
A hospice must notify the Department in writing within 24 hours of discovery of the defacement or destruction of patient medical records before termination of the required retention period pursuant to section 74896(b).
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