Oklahoma Administrative Code
Title 310 - Oklahoma State Department of Health
Chapter 662 - Home Care Agencies
Subchapter 3 - Administration
Section 310:662-3-5 - Clinical records
Current through Vol. 42, No. 1, September 16, 2024
(a) The agency shall establish and maintain a clinical record for each client receiving care and services. The record shall be complete, timely, accurately documented and readily accessible. Clinical records shall be kept confidential. The agency shall ensure confidentiality of client information in accordance with written policies and procedures. Records shall be stored in a locked area and only authorized personnel shall have access to the records.
(b) Clinical records are the property of the home care agency and may be released only upon the written consent of the client, the court appointed guardian, by a court order, or as otherwise authorized by law. Any person who has been a client of a home care agency shall be entitled to obtain copies of their clinical record as allowed by law. [76 O.S. 1991, §19]
(c) Clinical records shall be retained at least five (5) years beyond the date the client was last seen or longer as otherwise required by law.
(d) In addition to a plan of care, the clinical record shall contain:
(e) If skilled care is provided or if personal care is provided by an order of a physician, the clinical record shall also contain:
Added at 11 Ok Reg 3185, eff 6-27-94; Amended at 14 Ok Reg 2111, eff 4-7-97 (emergency); Amended at 14 Ok Reg 2274, eff 6-12-97