Current through Register Vol. 24-18, September 15, 2024
The licensee must:
(1) Maintain a current record for each
patient consistent with chapter 70.02 RCW;
(2) Ensure that patient records are:
(a) Accessible in the licensee's office
location for review by appropriate direct care personnel, volunteers,
contractors, and the department;
(b) Written legibly in permanent ink or
retrievable by electronic means;
(c) On the licensee's standardized forms or
electronic templates;
(d) In a
legally acceptable manner;
(e) Kept
confidential;
(f) Chronological in
its entirety or by the service provided;
(g) Fastened together to avoid loss of record
contents (paper documents); and
(h)
Kept current with all documents filed according to agency time frames per
agency policies and procedures.
(3) Except as provided in subsection (4) of
this section, include documentation of the following in each record:
(a) Patient's name, age, current address and
phone number;
(b) Patient's consent
for services, care, and treatments;
(c) Payment source and patient responsibility
for payment;
(d) Initial assessment
when providing home health services, except when providing home health aide
only services under WAC
246-335-540(5);
(e) Plan of care according to WAC
246-335-540, depending upon the
services provided;
(f) Signed or
electronically authenticated and dated notes documenting and describing
services provided during each patient contact;
(g) Observations and changes in the patient's
condition or needs;
(h) For
patients receiving home health, with the exception of home health aide only
services per WAC
246-335-540(5),
authorized practitioner orders and documentation of response to medications and
treatments ordered;
(i) Supervision
of home health aide services according to WAC
246-335-545(7);
and
(j) Other documentation as
required by this chapter.
(4) For patients receiving a one-time visit,
provide the documentation required in WAC
246-335-540(6)
in lieu of the requirements in subsection (3) of this section;
(5) Consider the records as property of the
licensee and allow the patient access to his or her own record; and
(6) Upon request and according to agency
policy and procedure, provide patient information or a summary of care when the
patient is transferred or discharged to another agency or facility.
(7) The licensee must keep patient records
for:
(a) Adults - Three years following the
date of termination of services;
(b) Minors - Three years after attaining age
eighteen, or five years following discharge, whichever is longer; and
(c) Patient death - Three years following the
last date or termination of services if patient was on services when death
occurred.
(8) The
licensee must:
(a) Store patient records in a
safe and secure manner to prevent loss of information, to maintain the
integrity of the record, and to protect against unauthorized use;
(b) Maintain or release records in accordance
with chapter 70.02 RCW; and
(c)
After ceasing operation, retain or dispose of patient records in a confidential
manner according to the time frames in subsection (7) of this
section.
