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General Description
Requirements
Policy Provisions
Performance Evaluation
Subject Experts
Clinical Documenation/Paperwork
Policy

Document Number: RWC--100 Revision #: 1.0
Document Owner: Executive VP Date Last Updated: 07/11/2013
Primary Author: Dean of the School of Nursing and Health Sciences and Health Sciences Status: Approved
Date Originally Created: 05/22/2012

General Description
Description:

Information about clinical documentation and paperwork for the Rudy Wellness Center.


Purpose:

Delineation of policy.


Scope:

All faculty, staff, students, and administrators


Responsibility: All faculty, staff, students, and administrators

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Requirements
Relevant Knowledge: In order to comply with this policy you should know:
Current University policy
Standards of good practice

Terms and Definitions: Additional training

Corrective Action

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Policy Provisions
1.

Clinical Documentation/Paperwork


It is important for Clinicians and Staff to be mindful of accurate recording of service activities.  An “electronic” client file is generated for all new clients and maintained on all continuing clients, using the Practice Fusion Web-Based Electronic Medical Record System.

 

When a student, employee, or staff member who is not already a client, is seen in an urgent situation outside of the Center, it is helpful to get “identification” information.  At the least, an attempt should be made to obtain a name, phone number, and a close relative or friend to contact should the individual’s situation worsen.  Clinically significant information received about any client who has sought services will be kept on file in the Practice Fusion Electronic Medical Record (EMR) at the Rudy Wellness Center.


2.

Clinical Records


An “electronic” clinical record will be established upon the first visit to the Rudy Wellness Center.  Each successive visit will also become part of the client’s clinical record.


3.

Initial Clinical Visit


The client seeking services is asked to complete a Medical History Form (Appendix B) prior to meeting with a clinician and this information is entered into the EMR as part of the client’s chart.  Each future visit will be documented in the SOAP section of the EMR.


4.

Informed Consent/Confidentiality


Confidential information may not be released or discussed with anyone, other than Center clinical staff, without the written consent of the client, except in accordance with law.    The Medical Release Form (Appendix G) must be signed and dated by the client in order clinical information to be released by the Rudy Wellness Center.   All records released by the Rudy Wellness Center will be stamped “Confidential”.

 

Requests for information from government agencies and attorneys or by court order or subpoena will be honored only upon advice of the University’s legal counsel and in accordance with the law.  A signed consent must be obtained whenever confidential information is to be released to a person or agency outside the Rudy Wellness Center, including to Cumberland University staff and faculty.

 

It is important to note that Residential Life staff and other campus offices have their own guidelines for the reporting of critical information and incidents, and are often accustomed to freer sharing of information in their work environment than is allowable for clinicians.  They may need to be reminded from time to time that clinicians are ethically and legally bound to much tighter constraints in this regard, and do not have the prerogative to share some types of information which other campus staff might ordinarily expect to exchange.


5.

Client Request for Copy of Records


The EMR, which includes all documentation pertaining to the client’s record, is considered property of the Rudy Wellness Center.  Most information contained in the record is considered property of the client.  Upon written request, the file may be reviewed with the client in the presence of the clinician and/or director.

 

Although they do not have a right to the EMR, clients are entitled to inspect and receive a copy of their records upon written request.  Under limited circumstances, a client’s request for a copy of records may be denied.  Clients do not have a right to any materials contained in the file that did not originate within the Rudy Wellness Center.  In such cases, the client should contact the originating source of the specific records. Upon request, the Rudy Wellness Center staff will provide the client with the name of the originating source and the contact information of that source.   If the clinician believes that access to files could be harmful, access may be denied to portions or even the entire file.

 

In order to receive a copy of their file, the client signs a Receipt for Confidential Records form (Appendix H).


6.

Progress Notes/Other Contacts


Clinicians should record progress notes in the EMR during or following each visit.  These notes are to be charted by the end of the day on which the client was seen.

 

Phone calls and other contacts with the client should be noted and recorded in the client’s EMR. Contact with other parties regarding the client should also be noted in the client’s EMR.


7.

Record Storage


The Electronic Medical Record system Practice Fusion, is a HIPAA compliant web based EMR. The EMR system has leveled access security. The Program Administrator sets the access level per individual.  All persons who have access to the EMR must sign a confidentiality agreement with the Center.  Each person is issued a login and they select a unique password.  Passwords are confidential and not shared.  In a web-based system all files are housed on a server off-site.  This provides security and disaster recovery for our medical records.

 

Records can be destroyed in accordance with law no less than 7 years from last date of service.  A record of client names and dates of service will be maintained in the Rudy Wellness Center upon destruction of client record.


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Performance Evaluation
Performance Metrics: Compliance with standard policy and procedure

Consequences: Further training

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Subject Experts
The following may be consulted for additional information.
Academic Affairs Support Staff

Dean of the School of Nursing and Health Sciences and Health Sciences

Executive VP

VP for Academic Affairs

Executive Director of Facilities and Safety

VP of Business and Finance

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