Current through Reg. 49, No. 52; December 27, 2024
(a) In accordance
with accepted principles of practice, a center must establish and maintain a
medical record system to ensure that the services provided to a minor are
completely and accurately documented, readily accessible, and systematically
organized to facilitate the compilation and retrieval of information.
(b) A center must establish a medical record
for a minor and must maintain the record in accordance with and contain the
information described in subsection (g) of this section.
(c) A center must keep a single file for
services provided to a minor and a minor's parent.
(d) A center must adopt and enforce written
procedures regarding the use and removal of records, the release of
information, and when applicable, the incorporation of clinical, progress, or
other notes into the medical record.
(e) A center may not release any portion of a
minor's medical record to anyone other than the adult minor or the minor's
parent, except as allowed by law.
(f) A center must establish a secure area for
original active medical record storage at the center's place of business.
(1) A center must ensure that a minor's
medical record is treated as confidential, safeguarded against loss and
unofficial use, and maintained according to professional standards of
practice.
(2) A center must keep a
minor's medical record in original form, as a microfilmed copy, on an
electronic system, or as a certified copy.
(3) A medical record in its original form is
a signed paper record or an electronically signed computer record.
(4) A center must ensure that electronic
medical records meet the requirements of paper records, including protection
from unofficial use as specified in subsection (f)(1) of this
section.
(5) A center must ensure
that an entry to a medical record regarding the delivery of services is not
altered without evidence and explanation of the alteration.
(6) A center must ensure that an entry to a
minor's medical record is current, accurate, legible, clear, complete, and
appropriately authenticated and dated with the date of entry by the individual
making the entry. The record must document all services provided on behalf of
the center. The center must not use correction fluid or tape in the record. The
center must make corrections by striking through the error with a single line
and including the date the correction was made and the initials of the person
making the correction.
(7) A center
must store the record of an inactive minor's medical record on paper,
microfilm, or electronically. The center must secure the medical record and
ensure that it is readily retrievable by the center staff.
(g) Each medical record must include the
following information as applicable to the services provided on behalf of a
center:
(1) a minor's referral and application
for services including, but not limited to:
(A) the minor's full name;
(B) the minor's sex and date of
birth;
(C) the name, address, and
telephone number of the minor's parent, or others as identified by the minor's
parent;
(D) the minor's prescribing
physician's name and telephone numbers, and an emergency contact number;
and
(E) the minor's prescribing
physician's initial order for services;
(2) comprehensive assessments, pertinent
medical history including allergies and special precautions, and subsequent
assessments;
(3) plans of care,
nursing care plans, and other plans as applicable;
(4) verbal orders of a physician reduced to
writing and signed by the physician in accordance with the center's policy as
required by §
550.702 of this subchapter
(relating to Receiving Physician Orders);
(5) documentation of nutritional counseling
and special diets, as appropriate;
(6) clinical and progress notes from all
professionals providing services to the minor;
(7) documentation of all known services and
significant events;
(8) current
medication list;
(9) medication
administration record, if medication is administered by center staff;
(10) current immunization record;
(11) written acknowledgment of the adult
minor's or the minor's parent's receipt of written notification of the
requirements of §
550.901 of this subchapter
(relating to Rights and Responsibilities);
(12) written acknowledgment of the adult
minor's or the minor's parent's receipt of a center's policy relating to the
reporting of abuse, neglect, or exploitation of a minor;
(13) written acknowledgement of the adult
minor's or the minor's parent's receipt of the notice of advance
directives;
(14) written
acknowledgement of the adult minor's or the minor's parent's receipt of the
center's policies relating to discipline and guidance;
(15) documentation demonstrating that the
adult minor or the minor's parent have been informed of how to register a
complaint in accordance with §
550.901 of this
subchapter;
(16) discharge summary,
including the reason for discharge or transfer and a center's documented notice
to the adult minor, the minor's parent, the minor's prescribing physician, and
other individuals as required in §
550.608 of this subchapter
(relating to Discharge or Transfer Notification);
(17) services provided to the minor's parent;
and
(18) all consent and election
forms, as applicable.
(h)
A center must ensure that clinical and progress notes are written the day
service is rendered and incorporated into the medical record no later than two
business days after the services are rendered.
(i) A center must ensure the retention of the
medical record for a minor meets the requirements in §550.1004 of this
division (relating to Retention of Records).
