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What must all pages of a patients medical record include?

Patients name and date of birth should appear on all pages of record. Patients condition(s) should be clearly documented in record. Documentation must be dated, if applicable, and start and stop time must be documented.

How long do you have to keep patient charts?

Each Medical Record shall contain sufficient, accurate information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among health care providers.

How long do you have to keep a deceased patients chart?

California. Hospitals in California must keep adult patient records for seven years after the last discharge date.

How long do you have to chart on a patient?

But did you know that some payers require that charts be signed within 48 hours? In such instances, if you do not sign the chart within the specified timeframe, the charts cannot be billed. So, if you do not sign your chart until three days after you see a patient, the chart is unbillable.