Policy Manual sample

MDT Home Health Care Agency, Inc. CLIENT’S CLINICAL RECORD NUMBERING SYSTEM POLICY A client’s clinical record number is assigned to each client’s clinical record. PURPOSES 1. To identify client’s clinical records. 2. To facilitate convenient and expedited access to client’s clinical records. PROCEDURES 1. At the time of a clients admission to the Home Health Care Agency, the Administrative Assistant assigns to the client a client’s clinical record number from the Client’s Clinical Record Log. 2. The Administrative Assistant documents the client’s clinical record number on the Client’s Clinical Record Index card, including the following information concerning the client: a. Name b. Address c. Phone Number d. Date of Birth e. Clinical record number f. Attending physician’s, PA, ARNP (Advanced Registered Nurse Practitioner), acting within their scope of practice, name and phone number g. Principal diagnosis h. Secondary diagnosis Payment source j. Admission date k. Discharge date l. Emergency Contact’s Name and phone number 3. The Medical Record Office clerk files completed Client’s Clinical Record Index cards or log, alphabetically according to client’s last name. A client’s card is filed in the active client’s clinical record index file if the client is a current admission to the Home Health Care Agency or in the inactive client’s clinical record index file if the client has been discharged from the agency. Home Health Agency Nursing Manual J-29