Q: Some of our providers see patients in our local nursing facilities. When those patients are admitted to our hospital, must we retain that documentation in our own records?
A: Neither The Joint Commission nor CMS require hospitals to retain documentation in their own records of physician visits at nursing homes.
If a patient from the nursing home presents to the hospital’s ED, the hospital should be able to simply call the nursing home and obtain any necessary documentation. This documentation can assist with continuity of care. However, there is no legal requirement for the hospital to retain this documentation within its own medical records as a matter of procedure.
Customarily, the nursing home sends information with patients who are transferred to the hospital. It’s best practice to keep this information in the patient’s hospital medical record.
If the hospital receives a request for the record (e.g., from an auditor), it must be able to easily access—and produce—the nursing home documentation. This documentation also likely helps to justify an admission to the hospital and can support hospital billing.
Editor’s note: Glenn Krauss, BBA, RHIA, CCS, FCS, PCS, CCS-P, CPUR, C-CDI, CCDS, is senior manager with Accretive Health in Chicago.Reach him at gkrauss@accretivehealth.com
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