MEDICAL RECORDS                                                                                           35-02-009

 

PURGING ACTIVE MEDICAL RECORDS

POLICY STATEMENT.

The Division of Veterans Healthcare Services (DVHS) requires each of the New Jersey Veterans Memorial Homes (VMH) to practice “purging” the Medical Records of residing residents to reduce the number of inactive pages in a resident’s Medical Record, in accordance with the New Jersey State Department of Health and Senior Services and the U.S. Department of Veterans Administration regulatory requirements.

PURPOSE.

This policy and procedure serves to ensure that each of the New Jersey Veterans Memorial Homes implements a process that periodically removes inactive pages of the Medical Record, reducing the number of inactive pages in the resident’s Medical Record that is kept at the nursing station.

DEFINITIONS.

Purging - the removal from a Medical Record of pages that are no longer actively needed by staff in
providing care to residents.

Interdisciplinary Team (IDT) - a group of staff members, both professional and ancillary, representative of each service, coordinated by a Registered Nurse (RN), and responsible for the development of individual resident care and treatment plans, in accordance with the New Jersey Department of Health and Senior Services’ licensing standards. 

PROCEDURE.

  1. The following list of forms may be deleted from active charts after the amount of time specified next to 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 record.
  2. History and Physical:                         Admission H&P, and the results of the most recent examination must remain in the chart.

    Medical Plan of Care and                  Initial certification and medical plan of care, and re-certification
    Recertification:                                   for the last six (6) months must remain in the chart.

    Physicians' Orders:                            Admission orders 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 and Treatment:               Initial records and records of all medication and treatment sheets. Treatments that have been provided during the last six (6) months must remain in the chart.

    Laboratory, Radiological and           Records of all laboratory, radiological and other diagnostic
    Diagnostic Tests:                                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.

  3. The Medical Record shall be thinned to provide for ease of use by the Interdisciplinary Team members by transferring original records into a secondary record know as an Overflow Record or Overflow File.  This will be accomplished while continuing to protect the medical record against loss, destruction, or unauthorized use.

    1. Each Veterans Memorial Home shall establish a monthly Thinning/Purging Schedule guiding how the Medical Record (Chart) will be thinned.

    2. The monthly thinning and maintenance of each Medical Record on the resident living units will be completed according to the established schedule.  Any required maintenance will be completed (papers reinforced, placed in plastic, etc.) when records are purged.  All stickers (DNR, DNH, Falls Precautions, etc.) will also be verified, as necessary.

    3. Any paperwork removed from the Medical Record will be inventoried (the name of the form and the time frame which the thinned paperwork reflects) on the Medical Record Thinning Checklist, secured, and placed in the Overflow Record / Overflow File.

    4. The current month is not included in the specified time-frame when thinning the Medical Record.  For example, the retention time for Physician’s Orders is six months and the current date is September 10, 2006.  Since the current month is not a complete month, the six months of orders that must remain in the Medical Record include August, July, June, May, April and March.

    5. The paperwork thinned or purged from the Medical Record will immediately be filed into the Overflow Record/ Overflow File.  The most recent information thinned will be placed in the front of the Overflow Record/ Overflow File.

Revised:   July 2007
Revised:   April 2010

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