Standard 6 Creation And Retention Of Accurate Patient And Institutional Records
All patient and institutional records are the property of the university. University personnel responsible for the preparation and retention of records shall ensure that those records are accurately prepared and maintained in a manner and location as prescribed by law and university policy.
- The complete and accurate preparation and maintenance of all records (medical, professional, electronic, paper, and institutional) by university physicians, clinicians, nurses, and others are important for providing quality care and conducting business of the university’s clinical enterprise. Accurate records are required in order for the university hospital or clinic to retain licensure and accreditation.
- University personnel will not knowingly create records that contain any false, fraudulent, fictitious, deceptive, or misleading information.
- University personnel must not delete any entry from medical a record. Medical records can be amended and material added to ensure accuracy of a record in accordance with medical center and Medical Staff policies and procedures. Whenever university personnel amend a record, they must indicate that the notation is an addition or correction and record the actual date that the additional entry has been made.
- University personnel must not sign someone else’s signature or initials on a record unless they have been authorized and clearly marked that they are signing on behalf of another (e.g., by initialing the signature).
- University records shall be maintained according to accepted standards and principles of the particular profession and applicable university policies and procedures.
- Unless authorized by university policy, university personnel shall not destroy or remove any university records from the university’s premises.
- The university’s record retention and record destruction policies and procedures must be consistent with Federal and State requirements regarding the appropriate time periods for maintenance and location of records.