Current through Register Vol. 35, No. 18, September 24, 2024
Each agency licensed pursuant to these regulations must
maintain the original record for each patient/client receiving services.
Patient/client records shall be made available for review upon request of the
licensing authority. Every record must be accurate, legible, promptly completed
and consistently organized. A patient/client record must meet the following
criteria:
A. Content of patient/client
record:
(1) Medically directed patient/client
record must include:
(a) past and current
medical findings in accordance with accepted professional standard;
(b) plan of care;
(c) identifying information;
(d) name of physician;
(e) medications, diet, treatment/services,
and activity orders;
(f) signed and
dated notes on the day service(s) provided;
(g) copies of summary reports sent to the
physician;
(h) evidence of
patient/client being informed of rights;
(i) evidence of coordination of care provided
by all personnel providing patient/client services;
(j) discharge summary.
(2) Non-medically directed patient/client
records must include:
(a) plan of
care;
(b) identifying
information;
(c) signed and dated
notes on the day service(s) provided;
(d) evidence of patient/client being informed
of rights;
(e) evidence of
coordination of care of all personnel providing patient/client
services;
(f) evidence of
discharge.
B.
If the patient/client is discharged or transferred to another provider of
health care, upon receipt of a signed request from the patient/client, a copy
of the original record or an abstract of the same must be made available to the
receiving facility, within 24 hours.
C. Protection of patient/client
records:
(1) The agency must insure
that the original patient/client records and information is safeguarded against
loss or unauthorized use.
(2) The
agency must have written policies and procedures governing the use and removal
of patient/client records and conditions for release of information.
(3) patient/client's written consent is
required for release of information not authorized by law.
D. Retention of patient/client records:
(1) Original patient/client records shall be
retained for at least 10 years after the patient/client is
discharged.
(2) Original
patient/client records shall be maintained for the requisite period even if the
agency has discontinued operations.
(3) The licensing authority must be notified,
in writing, prior to discontinuing operation of the storage location of
patient/client records.
