(a) A home health agency shall maintain a
clinical record for each patient. The clinical record must be legible and
maintained in accordance with accepted professional or occupational standards.
The clinical record must be readily available upon the request of the
(1) attending physician, advanced practice
registered nurse, or physician assistant:
(4) the patient's representative;
or
(5) if authorized by the
patient, another health care provider.
(b) A clinical record must include the
following items:
(1) appropriate identifying
information;
(2) assessments by
appropriate personnel;
(4) name of the
attending phvsician, advanced practice registered nurse, or physician
assistant;
(5) signed and dated
clinical progress notes;
(6) copies
of summary reports sent to the attending physician, advanced practice
registered nurse, or physician assistant;
(7) a signed patient release or consent
forms, if indicated;
(8)
documentation of informed consent regarding the initiation of care and
treatment, and changes in the plan of care;
(9) evidence the patient received the
patients' rights under
7
AAC 12.534 and advance directive information under
7
AAC 12.537;
(10) copies of transfer information sent with
the patient; and
(11) a discharge
summary.
(c) Clinical
progress notes must be written or dictated on the day that care or service is
rendered. The clinical progress notes must be incorporated into the patient's
clinical record within seven days. Summaries of the care or service reported
must be submitted to the attending physician, advanced practice registered
nurse, or physician assistant at least every 62 days.
(d) A home health agency shall have written
policies and procedures to provide that clinical records are
(1) legibly written in ink or typed, suitable
for photocopying;
(2) readily
available to authorized personnel during operating hours of the
agency;
(3) protected from
damage;
(4) if computerized, have a
security mechanism in place to ensure confidentiality;
(5) retained for five years after the date of
discharge, or, in the case of a minor, three years after the patient turns 21
years of age; agency policy and procedures must provide for record retention
even if the home health agency discontinues operation;
(6) disposed of using a method that will
prevent retrieval and subsequent use of information; and
(7) transferred with the patient if the
patient transfers to another agency or health facility; the transferred record
may be a copy or an abstract and a summary report.
