Current through August 30, 2024
(a) A hospice
agency shall establish and maintain a clinical record for each client receiving
care and services. The record must provide for identification, security,
confidentiality, control, retrieval, and preservation of client care data and
information. Each clinical record must be a comprehensive compilation of
information. The agency shall ensure that entries are
(1) made for all services provided, whether
furnished directly by or indirectly through the agency; and
(2) made and signed by the staff providing
the services.
(b) Each
client's clinical record must contain
(1)
appropriate identifying information;
(2) assessments by appropriate
personnel;
(3) the client's plan of
care;
(4) the name of the attending
physician or advanced practice registered nurse;
(5) signed and dated progress
notes;
(6) copies of summary
reports sent to the attending physician or advanced practice registered
nurse;
(7) a signed client release
or consent form;
(8) documentation
of informed consent regarding the initiation of care and treatment and changes
in the plan of care;
(9) evidence
that the client was informed regarding advance health care directives and
client rights as described in
7 AAC 12.320;
(10) copies of any transfer information sent
with the client; and
(11) a
discharge summary, if appropriate.
(c) Clinical progress notes must be written
or dictated on the day that care or service is provided. The clinical progress
notes must be incorporated into the client's clinical record within seven
days.
(d) A hospice agency shall
have written policies and procedures to ensure that clinical records are
(1) legibly written in ink or typed, and
suitable for photocopying;
(2)
readily available to authorized personnel during operating hours of the
agency;
(3) protected from
damage;
(4) if electronic,
protected by security software designed to ensure confidentiality;
(5) retained for at least five years after
the date of discharge, or in the case of a minor, three years after the client
turns 21 years of age; agency policies and procedures must provide for record
retention even if the agency discontinues operation;
(6) disposed of using a method that will
prevent retrieval and subsequent use of information; and
(7) transferred with the client if the client
transfers to another agency or health facility; the transferred record may be
(A) a copy; or
(B) an abstract and a summary
report.
(e)
In addition to maintaining clinical records as described in this section, a
hospice agency shall maintain administrative records that, at a minimum,
include
(1) minutes of governing body
meetings;
(2) all receipts and
expenditures; and
(3) training
provided to paid staff and volunteers.
Authority:AS
47.32.010
AS
47.32.030
