Current through Register No. 40, October 3, 2024
(a) The licensee
shall maintain a legible, current, and accurate record for each client based on
services provided at the ESRDDC which includes, at a minimum:
(1) The written confirmation required by
He-P 811.16(a) (2)
;
(2) The identification data required by
He-P 811.16(a) (3)
;
(3) Consent forms as required by
He-P 811.16(a) (4)
;
(4) Consent for release of information as
applicable required by
He-P 811.16(a) (5)
;
(5) The record of the medical history and
health examination required by
He-P 811.16(a) (6)
;
(6) All orders from a licensed practitioner,
including the date and signature of the licensed practitioner;
(7) Results of any laboratory
tests;
(8) All consultation
reports;
(9) All assessments for
the last 12 months;
(10) All care
plans for the last 12 months;
(11)
All written notes required by
He-P 811.16(b) (10)
;
(12) The medication record required by
He-P 811.17(t) and (v)
;
(13) Discharge or transfer documentation as
required by
He-P 811.16(e)
; and
(14) Documentation of nurse delegation of
medications as required by the nurse practice act, as applicable.
(b) Client records shall be:
(1) Safeguarded against loss, damage, or
unauthorized use; and
(2) Retained
for 7 years from the date of the patient's last contact with the licensee,
unless, before that date, the patient has requested that the file be
transferred to another health care provider, except that when the client is a
minor, records shall be retained for 7 years or until the person reaches the
age of 19, whichever is longer.
(c) The licensee shall arrange for storage of
and access to client records as required by (b) (2) above in the event the
ESRDDC ceases operation.
(d) The
licensee shall develop and implement a written policy and procedure document
that specifies the method by which release of information from a client's
record shall occur.
(e) Any
licensee that maintains electronic records shall develop written policies and
procedures designed to protect the privacy of clients and personnel that, at a
minimum, include:
(1) Procedures for backing
up files to prevent loss of data;
(2) Safeguards for maintaining the
confidentiality of information pertaining to clients and staff; and
(3) Systems to prevent tampering with
information pertaining to clients and staff.
#9963, eff
7-28-11
