Patient Care Facility Accreditation Guide

The Patient Records Standards address the centralization, accessibility, and protection of patient records, as well as the  security/confidentiality of Protected Health Information (PHI). Federal HIPAA regulations apply to all facilities providing DMEPOS services.

PR.1

You must have written policies and procedures that address the creation, confidentiality, security, and maintenance of patient records.

PR.2

You must maintain a secure patient record system that allows for the prompt retrieval of information. Patient records must be protected from risks, and appropriate measures must be taken to maintain reliable backups of all patient data.

Tip

You must have a system in place that allows you quick access to patient information. This system may be paper or electronic, and it must be secure.

PR.2.1

Your patient records must include federal, state, local, and applicable third-party payer-required documentation.

Tip

Patient records should include, but are not limited to, prescriptions, written orders, delivery receipts, payment authorizations, physician communications, progress notes, and any other required documentation.

PR.3

You must have a written policy that your patient records include the following:

1. Written, pictorial, or documented oral instructions related to the use, maintenance, cleaning, infection control practices for, and potential hazards of equipment and/or items

2. Verification that the equipment, items, and services were received

3. The make and model number of any non-custom equipment and/or items provided

Tip

At a minimum, patient records must include documentation that the patient received:

• The equipment, item(s) and/or service(s)
• The appropriate instructions on the use of equipment
• Information about the manufacturer’s guidelines or any other appropriate information for the maintenance of the item
• Education on how to properly clean the item
• Information on infection control issues and potential hazards

You must also document the make and model number of any non-custom items and equipment provided to the patient in your equipment log or similar tracking system.

PR.3.1

Your patient records must include:

1. Patient evaluation/assessment that contains diagnosis, prescription or valid order, relevant patient history and medical necessity

2. Pre-treatment photographic documentation as appropriate for the item

3. Patient education

4. The name and title of the patient care provider, their findings, recommendations, treatment plan, and follow-up schedule

Tip

All patient records must be consistent. If you use photographic documentation, you will have a policy that describes how, when, and under what circumstances photographic documentation is used. 

PR.3.1.1

Your patient records must document the patient’s need for and use of the orthosis, prosthesis, and/or pedorthic device, including, but not limited to:

1. Pertinent medical history

2. Allergies to materials

3. Skin condition

4. Diagnosis

5. Previous use of orthoses, prostheses and/or pedorthic devices

6. Results of diagnostic evaluations

7. Patient goals and expectations

PR.3.2

If you are providing complex rehabilitative and assistive technology, all of the information obtained during the assessment must be maintained in the patient’s record.

PR.4

You must have technical records that include a detailed description relevant to any orthosis, prosthesis and/or pedorthic device provided.

Tip

Documentation of this standard may include a detailed description of the device, materials, components, measurement forms, order forms, packing slips and delivery receipts.

PR.4.1

You must verify that seating, positioning, and specialty assistive technology have been evaluated and documented in the patient’s record.