Ind. IHCP Hospice Services Provider Reference Module, Section 4, Medical Records Standards

The FSSA reminds hospice providers that the hospice agency’s forms and the IHCP hospice forms are

considered medical documentation, meaning they must adhere to medical records standards and are subject

to the requirements under 42 CFR 418.104. Failure to comply with proper medical records standards may

affect a hospice provider’s licensure and accreditation status during a state hospice licensure survey.

The National Hospice Organization’s Hospice Operation Manual (Kilburn, Linda H., 1997) has clear

medical record guidelines for all hospice providers as follows:

The hospice medical record is a legal document. As such, it must be organized, written legibly in

pen or in type (no pencil) and without obliterations or embellishments. It should be completed

in a timely fashion so that at any point during the time the patient or family is in the care of the

hospice, the documentation accurately reflects current care plan, service being provided and the

status of the patient or family unit. The hospice should develop policies governing the format,

content, access, review procedures (including quality assurance and utilization review activities),

and a determination of the length of time that a medical record must be retained.

The FSSA has noted the following noncompliance with medical records standards on IHCP hospice forms,

as well as on the hospice agency forms submitted for dually eligible (Medicare and Medicaid) members:

• The use of correction fluid rather than the staff person appropriately correcting an error by crossing

out the error and noting the staff person’s initials by the cross-out

• Failure of the hospice personnel to sign or date the forms, including the hospice agency’s physician

certification or hospice plans of care that are submitted for dually eligible members

• Submitting a packet of paperwork that reflects hospice discharge on a particular date due to the

hospice member’s date of death, yet the hospice physician still signed the hospice certification form

the date after this individual died, recertifying the individual for another hospice benefit period

(reflects lack of review of the hospice medical chart by internal quality assurance reviewer)