North Carolina Administrative Code
Title 10A - HEALTH AND HUMAN SERVICES
Chapter 13 - NC MEDICAL CARE COMMISSION
Subchapter J - THE LICENSING OF HOME CARE AGENCIES
Section .1400 - SERVICE RECORDS
Section 13J .1402 - CONTENT OF RECORD
Universal Citation: 10A NC Admin Code 13J .1402
Current through Register Vol. 39, No. 6, September 16, 2024
(a) If the agency is providing services to a client, the service record shall contain the following information:
(1) Admission data:
(A) identification data such as name,
address, telephone number, date of birth, sex, and marital status;
(B) a copy of the signed client's rights form
or documentation of its delivery;
(C) names of next of kin, legal guardian, or
other family members;
(D) source of
referral; and
(E) assessment of
home environment.
(2)
Service data:
(A) initial assessments by the
health care practitioner of the client's functional status in the areas of
social, mental, physical health, environmental, economic, ADLs, and
IADLs;
(B) identification of
problems, the establishment of goals and proposed intervention, and indication
of the client's understanding of and approval for services to be provided. If
the client is diagnosed as not competent, the approval of the client's
responsible party shall be recorded;
(C) a record of all services provided with
entries with date and time of service, and signed by the individual providing
the service;
(D) discharge summary
that includes an overall summary of services provided by the agency and the
date and reason for discharge. When a specific service to a client is
terminated and other services continue, there shall be documentation of the
date and reason for terminating the specific service; and
(E) evidence of coordination of services when
the client is receiving more than one in-home care service.
(b) If the agency is providing services to a client that require a physician's order, the service record shall include all of the items described in Paragraph (a) of this Rule and the following items:
(1) Admission data:
(A) admission and discharge dates from
hospital or other institution when applicable; and
(B) names of physician(s) responsible for the
client's care.
(2)
Service data:
(A) client's
diagnoses;
(B) physician's orders
for pharmaceuticals and medical treatments; and
(C) if the agency is providing services to a
hospital or nursing facility patient, the agency's record shall include
referral information, dates and times of services, and documentation of
services provided.
Authority
G.S.
131E-140;
Eff. July 1,
1992;
Amended Eff. February 1, 1996;
Readopted Eff.
June 1, 2018.
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