Current through Register Vol. 51, No. 19, September 20, 2024
A. With the
exception of §B of this regulation, an agency shall ensure that a clinical
record is maintained for each client in a manner that ensures security and
confidentiality, and includes at a minimum:
(1) The documentation required by §D of
this regulation;
(2) Any currently
effective health care orders;
(3)
Nurse's assessment
(4)
Rehabilitation plans, if appropriate;
(5) The care plan;
(6) Medications administered or taken,
including:
(a) Dosage;
(b) Route of administration; and
(c) Frequency;
(7) History of sensitivities or allergic
reactions;
(8) Nutritional
requirements, including specific dietary plans;
(9) Medically necessary supplies and
equipment;
(10) Care
notes;
(11) The name, address, and
telephone number of:
(a) The client's
physicians; and
(b) The client
representative; and
(12)
The following documents for each client upon discharge:
(a) Directions for the safe continuation of
care after discharge; and
(b) If
skilled services have been provided, a discharge summary that includes the
reason for discharge.
B. An agency that provides care to clients
who are assessed as not requiring certified caregivers or skilled services
shall maintain a client record, including but not limited to:
(1) Nursing assessment;
(2) Plan of care;
(3) Services provided;
(4) Any significant change of condition;
and
(5) Any other pertinent
information regarding the client being served.
C. An agency shall develop policies and
procedures to ensure that all information relating to a client's condition or
preferences, including any significant change of condition as defined in
Regulation .02B(27) of this chapter, is documented in the client's record and
communicated in a timely manner to:
(1) The
client;
(2) The client
representative, if appropriate; and
(3) All appropriate health care professionals
and staff who are involved in the development and implementation of the
client's care plan.
D.
Care Notes.
(1) Appropriate staff shall write
care notes for each client, at a minimum:
(a)
On admission and at least weekly;
(b) Upon any significant changes in the
client's condition; and
(c) When
the care plan is modified.
(2) The agency shall ensure that all notes
and reports that are entered in the clinical record, which may include an
electronic record, are detailed, legible, chronological, dated, and signed with
the name and title of the individual rendering the service.
E. The agency may accept orders
for care with an electronic signature. Orders may be received by, but not
limited to, mail, hand delivery, or facsimile transmission.
