Current through Reg. 49, No. 38; September 20, 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 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 an adult minor and a 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 computerized
medical records meet the requirements of paper records, including protection
from unofficial use as specified in subsection (g) of this section and
retention for the period specified in § 550.1004 of this division
(relating to Retention of Records).
(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) a minor's full name;
(B) sex and date of birth;
(C) the name, address and telephone number of
a minor's parent, or others as identified by a minor's parent;
(D) a minor's prescribing physician's name
and telephone numbers, and an emergency contact number; and
(E) a 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 a 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 an adult
minor's and a 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 an adult minor's and a 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 an adult minor's and a minor's parent's receipt of the notice of advance
directives;
(14) written
acknowledgement of an adult minor's and a minor's parent's receipt of the
center's policies relating to discipline and guidance;
(15) documentation demonstrating that an
adult minor and a 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 an adult minor, a
minor's parent, a 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 a minor's parent; and
(18) all consent and election forms, as
applicable.
(h) The
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.
