Medical Record Model for Dialysis Facilities

September 1, 2009 | Healthcare Risk, Quality, & Safety Guidance

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The Centers for Medicare and Medicaid Services’ (CMS) Conditions for Coverage for dialysis facilities provide risk management guidance on documentation and management of medical records. Accurate and complete documentation within the medical record is essential because CMS surveyors will review medical records to evaluate a facility’s compliance with the Conditions for Coverage. In addition to the requirements outlined in the Conditions for Coverage, facilities must adhere to Health Insurance Portability and Accountability Act privacy and security rules to prevent unauthorized disclosure of patients’ protected health information and to safeguard against the loss, destruction, or unauthorized disclosure of the medical record.

Suggestions for the content of dialysis facilities’ medical records have been compiled by the National...

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