CMS Manual System - Louisiana Department of Health and Hospitals

There is a written policy, at the health care facility, describing the attestation
policy(ies) in force at the facility.
The computer has built-in safeguards to minimize the possibility of fraud.
Each person responsible for an attestation has an individualized identifier.
The date and time is recorded from the computer‘s internal clock at the time of
entry
An entry is not to be changed after it has been recorded.
The computer program controls what sections/areas any individual can access or
enter data, based on the individual‘s personal identifier (and, therefore his/her
level of professional qualifications).
Procedures §483.75(l)(1)
In reviewing sampled residents‘ clinical records:
Is there enough record documentation for staff to conduct care programs and to
revise the program, as necessary, to respond to the changing status of the resident
as a result of interventions?
How is the clinical record used in managing the resident‘s progress in maintaining
or improving functional abilities and mental and psychosocial status?
§483.75(l)(5) the clinical record must contain--
(i) Sufficient information to identify the resident;
(ii) A record of the resident’s assessments;
(iii) the plan of care and services provided;
(iv) The results of any preadmission screening conducted by the State; and
(v) progress notes.
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§483.75(l)(2) Clinical records must be retained for--
(i) The period of time required by State law; or