15.HCS.IM.3 ( HCS)
The program maintains complete and accurate medical records.
Rationale
(0 comments)
• IM.3 1. The medical record contains sufficient information to identify the patient.
2. The program documents in the patient’s medical record information pertaining to the course and results of care, treatment, and services.
3. The program documents in the patient’s medical record enough information about the patient to promote continuity of care among providers, both internal and external to the program.
4. The program reviews its medical records for completeness and accuracy within its defined time frames.
5. The program retains records, data, and information in accordance with law and regulation.
Comments