Current through Register Vol. 50, No. 9, September 20, 2024
A.
Requirements. A clinical record containing past and current findings shall be
maintained either electronically or in paper form for every patient who is
accepted by the agency for home health service and shall be accessible to
authorized agency staff as needed. In addition, the agency shall comply with
the following requirements for clinical records.
1. The information contained in the clinical
record shall be accurate and immediately available to the patient's authorized
healthcare provider and appropriate HHA staff. The record may be maintained
electronically.
2. All entries
shall be legible, clear, complete, and appropriately authenticated and dated.
Authentication shall include signatures or a secured computer entry with the
unique identifier of a primary author who has reviewed and approved the
entry.
3. The original clinical
records of active patients may be kept in the branch office for the convenience
of the staff providing services. The records of patients whose services are
provided by parent office staff shall be kept in that office.
4. All clinical records shall be safeguarded
against loss, destruction and unauthorized use.
5. A signed consent for treatment form shall
be obtained from the patient and/or the patient's family and retained in the
record.
6. When applicable, a
signed release of information form shall be obtained from the patient and/or
the patient's family and a copy shall be retained in the record.
7. Records maintained either in paper or
electronically shall be made available to LDH staff upon request.
8. Records shall be retained either
electronically or in paper form for a period of not less than six years from
the date on which the record was established and, if there is an audit or
litigation that involves the records, the timeframe may be extended.
9. The agency shall have internal policies
that provide for the retention of clinical records even if the agency
discontinues operation.
10.
Repealed.
11. Repealed.
B. Clinical Note. A clinical note
shall be legibly written by the person making the visit and incorporated into
the clinical record within one week of the visit. A patient care clinical note
shall be completed on each visit and shall contain the following, at a minimum:
1. the date of the visit;
2. time of arrival;
3. time of exit;
4. services rendered and/or justification for
the visit;
5. signature of the
person making the visit;
6. vital
signs, according to authorized healthcare provider's order or accepted
standards of practice; and
7.
comments when indicated.
NOTE: The patient or a responsible person shall sign the
permanent record of visit that is retained by the agency. However, it is not
necessary for the patient or a responsible person to sign on the clinical
note.
C. Clinical
Record Contents. An active clinical record shall contain all of the following
documentation:
1. the initial
assessment;
2. the current POC
signed and dated by the authorized healthcare provider.
3. the current comprehensive
assessment;
4. the current clinical
notes for at least the past 60 days, including a description of measurable
outcomes relative to the goals in the POC that have been achieved;
5. identifying data, including:
a. name;
b. address;
c. date of birth;
d. gender;
e. agency case number; and
f. next of kin;
6. the date that care started;
7. attending authorized healthcare provider
data, including:
a. name;
b. address; and
c. telephone number;
8. the diagnoses, including all conditions
relevant to the current POC;
9. the
types of services rendered, including frequency, duration and the applicable
clinical notes;
10. a list of
current medications indicating the drug, dosage, frequency, route of
administration if other than oral, dates that a drug was initiated and
discontinued, drug allergies, dates that non-prescription remedies were
initiated and discontinued, side effects and a tracking procedure, and any
adverse reactions experienced by the patient;
11. the current medical orders;
12. diet;
13. functional status;
14. rehabilitation potential;
15. the prognosis;
16. durable medical equipment available
and/or needed;
17. when applicable,
a copy of the transfer form that was forwarded to the appropriate health care
facility that shall be assuming responsibility for the patient's care;
and
18. the discharge
summary.
AUTHORITY
NOTE: Promulgated in accordance with
R.S.
36:254 and
R.S.
40:2116.31 et
seq.
