MEDICAL RECORDS 35-02-001
PROFESSIONAL PRACTICE STANDARDS FOR LONG TERM CARE
The Division of Veterans Healthcare Services (DVHS) requires that each of the New Jersey Veterans Memorial Homes (VMH) establish a Medical Records Department, charged with the review and maintenance of the clinical records for residing residents, in accordance with the Professional Practice Standards for Long-Term Care, and in compliance with established Federal and State Regulatory requirements. The Medical Records Department shall be responsible for storing the records in a secure manner, retrieving the records efficiently, and providing access only to those authorized.
This policy and procedure shall ensure the confidentiality of the healthcare record, and ensure that healthcare records are complete, accurately documented, readily accessible and systematically organized in accordance with the Professional Practice Standards for Long Term Care.
A. Requirements for the Medical Record staff education and training program shall be as provided in N.J.A.C. 8:43G-5.9.
1. PRACTICE STANDARD I (CONTENT OF THE HEALTH RECORD)
INITIATE, FACILITATE, AND PROMOTE THE ATTAINMENT OF HIGH QUALITY CONTENT OF HEALTH RECORDS IN ACCORDANCE WITH FACILITY POLICIES.
RATIONALE: Health care delivery, planning, research and other administrative activities are dependent upon health care data supported by timely and adequate documentation of quality patient care.
2. PRACTICE STANDARD II (HEALTH CARE DATA)
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.
3. PRACTICE STANDARD III (CONFIDENTIALITY)
UPHOLD THE CONFIDENTIALITY OF HEALTH RECORD INFORMATION AND PROTECT THE 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 authorizes, or as required by statute. The physical chart, however, remains the property of the VMH.
4. PRACTICE STANDARD IV (RETENTION AND RETRIEVAL)
PROVIDE SYSTEMS FOR HEALTH DATA/RECORD RETRIEVAL AND RETENTION, WHICH MEET THE NEEDS OF HEALTH CARE CONSUMERS, FACILITIES, AND PROVIDERS.
RATIONALE: Since confidential health data are used in continuing patient care as well as for administrative, legal, quality assurance, research and educational purposes, the records must be organized in a manner that assures records can be easily retrieved, while maintaining the security and control of the data.
5. PRACTICE STANDARD V (MANAGEMENT AND SUPERVISION)
UTILIZE EFFECTIVELY THE AVAILABLE RESOURCES IN PERFORMING MANAGEMENT AND SUPERVISORY FUNCTIONS.
RATIONALE: 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 goals.
6. PRACTICE STANDARD VI (EXTERNAL REQUIREMENTS AND STANDARDS)
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, and accreditation status of the health care facility.
Revised: July 2007