Section 425.20 - Clinical records

425.20 Clinical records. The operator must:

(a) provide a clinical record for each registrant in accordance with the clinical records requirements of section 415.22 of this Subchapter;

(b) ensure that all reports and information pertaining to registrant care and planning are entered promptly;

(c) ensure that all entries are dated and authenticated by the person making the entry or ordering the services;

(d) ensure that all clinical records for registrants referred by a managed long term care plan or care coordination model are made available to the referring managed long term care plan or care coordination model;

(e) ensure that the record is kept in a place convenient for use by authorized staff; and

(f) retain intact clinical records and all other records of registrants and keep them readily accessible in a safe and secure place. Such records shall be retained safely and securely for a period of six years following discharge or cessation of operation of services. In the case of a minor, retention shall be for three years after reaching majority (18 years of age).

Effective Date: 
Wednesday, September 10, 2014
Doc Status: 
Complete