CMS SOM App. B, Tag G1008

The HHA must maintain a clinical record containing past and current information

for every patient accepted by the HHA and receiving home health services.

Information contained in the clinical record must be accurate, adhere to current

clinical record documentation standards of practice, and be available to the

physician(s) or allowed practitioner(s) issuing orders for the home health plan of

care, and appropriate HHA staff. This information may be maintained

electronically.

Interpretive Guidelines §484.110

The HHA must use the information contained in each medical record to assure that safe

care is delivered to each HHA patient. In accordance with the provisions of the Patient

rights Condition at §484.50(c)(6), the HHA must ensure the confidentiality of each

patient’s clinical record.

The manner and degree of noncompliance identified in relation to the standard level tags

for §484.110 may result in substantial noncompliance with this CoP, requiring citation at

the condition level.