MEDICAL RECORDS 35-02-008
COMPLETION OF MEDICAL RECORDS
The Division of Veterans Healthcare Services (DVHS) requires each of the New Jersey Veterans Memorial Homes (VMH) to establish a “Tickler File” system that ensures all Medical Records are completed within thirty (30) days of discharge or death.
This policy and procedure serves to ensure that each of the New Jersey Veterans Memorial Homes implements a record-tracking system that ensures all Medical Records are completed within thirty (30) days of discharge or death.
Complete Medical Record - an error-free or deficiency-free record; a discharge summary and an interdisciplinary 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.
The following list outlines the steps for prompt completion of Medical Records:
Revised: July 2007