Current through Register Vol. 18, September 20, 2024
(1) Each home infusion therapy agency shall
establish and maintain for each patient accepted for care, a medical record
which must be accessible to home infusion therapy personnel and which must
include the following information:
(a)
admission data, including the:
(i)
name;
(ii) current
address;
(iii) date of
birth;
(iv) sex;
(v) date of admission;
(vi) name and contact information of the
patient's caregiver or family member; and
(vii) name and contact information of the
pharmacist-in-charge and the prescribing practitioner.
(b) admission diagnosis and pertinent health
information relevant to the plan of care;
(c) any allergies and known adverse reactions
to drugs and food. This information must be given such prominence in the record
so as to make it obvious to any persons who provide food or medication to the
patient;
(d) laboratory
reports;
(e) documentation that a
list of patient rights and responsibilities have been made available to each
patient or the patient's caregiver;
(f) the plan of care;
(g) clinical assessments and services
documentation;
(h) the prescribing
practitioner's order for home infusion therapy;
(i) a monthly clinical therapy summary for
any patient receiving services 30 days or longer; and
(j) a discharge summary of therapy at the end
of treatment.
(2) The
responsibilities of the patient and the home infusion therapy agency, including
any contracted parties, in the areas of delivery of care and monitoring of the
patient, must be clearly documented in the patient's medical record.
(3) The home infusion therapy agency, and any
contracted party providing services to the patient, together, shall develop a
plan of care within three working days of the initiation of therapy, which must
include:
(a) a diagnosis;
(b) the types of services and equipment
required;
(c) the access device and
route of administration;
(d) the
estimated length of service;
(e) a
statement of treatment goals;
(f)
the regimen and prescription ordered;
(g) the concurrent legend and over the
counter drugs;
(h) an assessment of
mental status;
(i) permitted
activities;
(j) the prognosis,
discharge, transfer or referral plan; and
(k) instructions to patient and
family.
(4) All records
of dispensed sterile pharmaceuticals must be a part of the patient's medical
record.
50-5-103,
MCA; IMP,
50-5-103,
50-5-213,
MCA;
