Current through Bulletin 2024-06, March 15, 2024
(1) The
administrator shall develop and implement record keeping policies and
procedures that address the use of patient records by authorized staff,
content, confidentiality, retention, and storage.
(a) The licensee shall ensure that records
are organized in a uniform medical record format.
(b) The licensee shall maintain an
identification system to facilitate location of each patient's current or
closed record.
(c) The licensee
shall maintain an accurate, current record for each patient receiving
service.
(d) Each licensee who has
a patient contact or provides a service shall insure that a clinical note entry
of that contact or service is made in the patient's record.
(e) Any entries shall be dated and
authenticated with the signature and title of the person making the
entry.
(f) The licensee shall
document each service provided and the outcome of each service in the
individual patient record.
(2) The licensee shall ensure that signed and
dated physician's orders are incorporated into the plan of care and renewed at
least every 90 days. A copy of the order is acceptable as long as the original
order is available on request.
(3)
The licensee shall ensure that each patient record shall contain at least the
following information:
(a) demographic
information that includes:
(i) patient
name;
(ii) patient
address;
(iii) age;
(iv) patient date of birth;
(v) name and address of nearest relative or
responsible person;
(vi) name and
telephone number of the physician with primary responsibility for patient care;
and
(vii) name and telephone number
of the person or family member who, in addition to agency staff, provides care
in the place of residence;
(b) diagnosis;
(c) pertinent medical and surgical history if
available;
(d) a written and signed
informed consent to receive hospice services;
(e) orders by the attending physician for
hospice services;
(f) medications
and treatments as applicable;
(g) a
written plan of care; and
(h) a
signed, dated patient assessment that includes the following:
(i) a description of the patient's functional
limitations;
(ii) a physical
assessment noting chronic or acute pain and other physical symptoms and their
management;
(iii) a psychosocial
assessment of the patient and family;
(iv) a spiritual assessment; and
(v) a written summary report of hospice
services provided that is additionally sent to the patient's attending
physician at least every 90 days.
(4) The person who is assigned to supervise
or coordinate care for a patient shall complete a discharge summary when
services to the patient are terminated. The discharge summary shall include the
reason for discharge and the name of the facility or agency if the patient is
referred or transferred.
(5) The
licensee shall safeguard clinical record information against loss, destruction,
and unauthorized use.
(a) The licensee shall
ensure that written procedures govern the use and removal of records and
conditions for release of patient information.
(b) A written consent is required for the
release of patient information and photographing recorded
information.
(c) When a patient is
transferred to another facility or agency, the licensee shall send a copy of
the record or abstract to that service agency.
(6) The licensee shall provide an accessible
area for filing and safe storage of medical records.
(a) The licensee shall ensure that each
patient record is retained for at least seven years after the last date of
patient care.
(b) The licensee
shall transfer any patient records to a new owner upon a change of agency
ownership.
