Current through Register Vol. 51, No. 19, September 20, 2024
A. A
clinical record shall be maintained for each patient in accordance with
accepted professional standards, including, at a minimum:
(1) All pertinent diagnoses;
(2) Name, address, and telephone number of
physicians;
(3) Physician's orders,
including specific instructions for services to be rendered, activities and
limitations, and medically-necessary supplies and equipment;
(4) Drug information, including type, dosage,
route of administration, frequency, and history of sensitivities or allergic
reactions;
(5) Nutritional
requirements, including specific dietary plans;
(6) Prognosis, including rehabilitation
potential;
(7) Patient care plans,
which should include:
(a) Long and short-range
goals;
(b) Physical needs,
including safety measures to protect against injury;
(c) Psycho-social needs;
(d) Actions taken by individual disciplines;
and
(e) Evidence of periodic
reappraisal of the needs of the patient;
(8) Progress notes and modifications to the
treatment plan; and
(9) Discharge
summary.
B. The home
health agency should maintain a unit record for all patients receiving
multi-disciplinary care.
C. All
notes and reports entered in the clinic record shall be typewritten or written
in ink, legible, dated and signed with the name and title of the person
rendering service.
D. The home
health agency shall establish and implement policies concerning clinical
records which assure:
(1) That records of
discharged patients are completed no later than 30 days after the date of
discharge;
(2) The proper operation
of a system for identifying, filing, and retrieving clinical records;
(3) Proper mechanisms for the timely transfer
of clinical record information upon request from duly-authorized persons and
organizations;
(4) Proper
safeguards for clinical record information against loss, destruction, or
illegal or unauthorized use;
(5)
That clinical records are preserved for at least 5 years from the date of
discharge;
(6) That, with the
approval of the Department, provisions are made for retention of clinical
records when it ceases operation; and
(7) That progress notes are recorded within 5
working days after service is delivered. The treatment plan shall be modified
accordingly.
E. A home
health agency which provides maintenance health care or in-home services, or
both, may not be required to maintain the same level of supervisory and
record-keeping requirements of these regulations for those patients who only
receive the maintenance health or in-home services. In these cases, the agency
shall develop performance criteria, supervisory and record-keeping requirements
for these patients.
