Code of Massachusetts Regulations
105 CMR - DEPARTMENT OF PUBLIC HEALTH
Title 105 CMR 141.000 - Licensure of Hospice Programs
Section 141.209 - Clinical Records

Universal Citation: 105 MA Code of Regs 105.141

Current through Register 1531, September 27, 2024

(A) The hospice shall maintain in a centralized location at the hospice administrative office an accurate clinical record for every individual receiving care and services.

When a hospice patient is admitted to a hospice inpatient facility, a copy of the patient's plan of care and sufficient relevant supporting documentation to ensure coordination of care shall be transmitted to the inpatient facility. When the patient is discharged from the hospice inpatient facility, a medical record and discharge summary shall be transmitted to the hospice administrative office to be included in the patient's clinical record.

(B) The record shall be complete, promptly and accurately documented, readily accessible and systematically organized to facilitate retrieval. The refusal of services shall also be documented.

(C) Record entries shall be made and signed by the person providing the service for all services provided.

(D) The record shall include documentation of all services whether furnished directly or under arrangements made by the hospice.

(E) Each individual's record shall include:

(1) the initial and subsequent assessments;

(2) the plan of care;

(3) identification data;

(4) consent forms;

(5) pertinent medical history;

(6) complete documentation of all services and events (including evaluations, treatments, progress notes etc.);

(7) primary care providers' orders;

(8) medication records;

(9) discharge/transfer records;

(10) all pertinent diagnoses;

(11) the patient's prognosis;

(12) designation of the attending physician or medical team;

(13) a bereavement assessment and plan for intervention, if any; and

(14) instructions to the family concerning care if patient is discharged.

(F) The hospice shall safeguard the clinical records against loss, destruction and unauthorized use.

(G) All records shall be maintained for a period of seven years after death or discharge.

(H) Each hospice shall establish policies and procedures to govern the use, removal and, permanent disposition of records and determine the conditions of release of information in accordance with maintaining confidentiality.

Disclaimer: These regulations may not be the most recent version. Massachusetts may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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