Understanding Clinical Record Requirements in Home Health
Maintaining accurate, timely, and secure clinical records is essential in home health care. These records are more than just documentation—they ensure continuity of care, legal compliance, and the safety and well-being of patients. In April 2024, updated guidance clarified and emphasized specific expectations regarding clinical records. Below is a comprehensive breakdown of what home health staff need to know.
Discharge and Transfer Summaries: Timeliness Matters
One of the most significant updates involves the timeliness and communication of discharge and transfer summaries. These summaries play a crucial role in ensuring a smooth transition of care, whether a patient is being discharged or transferred to another healthcare setting.
Discharge Summary
When a patient is discharged from home health, a complete discharge summary must be prepared and sent to the primary care provider or other healthcare professional responsible for the patient's ongoing care. This summary must be sent within five business days of the discharge order being issued by the physician.
The discharge summary typically includes:
Admission and discharge dates
Name of the physician overseeing the plan of care
Reason for home health admission
Types and frequency of services provided
Laboratory data (if applicable)
List of current medications at discharge
Patient’s condition at discharge
Outcomes related to plan of care goals
Post-discharge instructions for patient and family
Transfer Summary
If a patient is transferred to another healthcare facility, two scenarios are considered:
Planned Transfer: When a transfer is scheduled in advance, the transfer summary must be sent within two business days of the planned transfer date.
Unplanned Transfer: If a transfer happens unexpectedly and the home health agency becomes aware while the patient is still receiving care at the new facility, the transfer summary must be sent within two business days of becoming aware of the transfer.
Transfer summaries generally mirror the content of discharge summaries and should provide the receiving facility with comprehensive, up-to-date patient information.
Authenticating Clinical Records
Every entry in a clinical record must be legible, clear, complete, and properly authenticated. This means:
Including the full name and title (e.g., RN, PT) of the person making the entry
Providing a dated and timed signature or using a secure electronic system with a unique identifier
Ensuring that the person signing has reviewed and approved the entry
Proper authentication supports accountability and ensures the record can be trusted during patient care, audits, or legal review.
Retention of Clinical Records
Home health agencies are required to retain patient clinical records for at least five years after discharge, unless state law requires a longer retention period.
If an agency closes or discontinues operation, it must have a plan in place for record retention and must inform the state health department where and how records will be stored and accessed in the future.
Protecting Patient Information
With frequent travel and remote work involved in home health, protecting patient information is critical. All clinical records must be safeguarded against loss, theft, or unauthorized access. This includes paper records and electronic devices used by staff.
Some important practices include:
Locking paper records during transport
Using password-protected and encrypted devices
Not leaving records unattended in vehicles or public areas
Providing regular HIPAA training to all staff, including contractors
Agencies must develop strong internal policies and ensure all team members understand and follow procedures for confidentiality and security.
Providing Records to Patients
Patients have the right to access their clinical records. When a request is made, the agency must provide a copy—either paper or electronic—at no cost to the patient. This must happen no later than the next home visit or within four business days, whichever comes first.
This policy reinforces patient autonomy and supports transparent care.
Final Thoughts
Timely communication, strong documentation, secure handling of information, and patient access are cornerstones of high-quality home health care. With these updated expectations in place, agencies must stay proactive in reviewing their policies, training staff, and ensuring compliance at every step. Not only does this support regulatory standards—it reflects the professionalism and commitment that every patient deserves.
