05/22/2023
Compliance holding up?
Take a moment to read this page from NYC state healthcare compliance laws and consider your clinic's risk with this snippet of the New York laws for medical clinics......
If you get overwhelmed, don't worry we will take care of all of your documentation for you with forms, automation and digitization of all of your office files!
DOCUMENTATION & RECORD KEEPING
Medical Record Documentation
HHC employed and affiliated Physicians and Healthcare
Providers should maintain accurate and complete medical
records and documentation of the services they provide.
They also should ensure that the claims they submit for pay-
ment are supported by the documentation.
Good
documentation practice helps ensure that your patients
receive appropriate care. It also helps you address chal-
lenges raised against the integrity of bills and claims sub-
mitted. The medical record should include (at minimum):
i. Physical examination including health history;
ii. Diagnosis/clinical impressions (admitting & final);
iii. Results of all consultative evaluations of the patient;
iv. Documentation of all complications;
v. Patient progress and changes in care or treatment;
vi. Properly executed consents for care;
vii. All orders, nursing documentation, reports of treatment, med-
ication records, radiology and laboratory reports, vital
other patient monitoring information; and
viii. Discharge summary with outcomes and follow-up care.
Document Retention and Destruction
HHC’s Operating Procedure (OP) 120-19 sets forth the poli-
cy and procedure governing the retention period and de-
struction schedule of all HHC records regardless of form or
medium (i.e. paper, electronic, voice, e-mail, etc.) gener-
ated by all HHC Workforce members in the normal course
of business. The OP also provides guidance concerning the
preservation of records for archival and legal purposes. All
records must be retained and destroyed in accordance
with applicable law and HHC’s record retention policy.
