MEDICAL RECORDS                                                                                           35-02-008

COMPLETION OF MEDICAL RECORDS

 

POLICY STATEMENT.

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.

PURPOSE.

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.

DEFINITION.

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.

PROCEDURE.

The following list outlines the steps for prompt completion of Medical Records:

  1. Remove the chart from the nursing unit and obtain all purged portions of the record from the Medical Records Department files.

  2. Use the "Medical Records Discharge Check List" to assemble the chart and document deficiencies.

  3. Alert any departments of charting deficiencies or discharge summaries that need to be completed.

  4. 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.

  5. Assign the correct ICD-9-CM code to the final diagnosis and record it in the Disease Index.

  6. 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.

  7. Sign and date the "Medical Records Discharge Check List" to verify completeness.

  8. Properly secure and file the Medical Record.

Revised:   July 2007
Revised:   April 2010

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