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Title: Section 766.6 - Patient care record

Effective Date


766.6 Patient care record. (a) The agency shall maintain a confidential record for each patient admitted to care to include:

(1) identifying patient data;

(2) medical orders, if applicable;

(3) nursing assessments conducted to provide services;

(4) an individualized plan of care;

(5) signed and dated progress notes following each patient visit or phone contact by all professional personnel providing care which include a summary of patient status and response to the plan of care and any contacts with family, informal supports and other community resources that are relevant to the patient's condition and treatment;

(6) supervisory reports of the registered professional nurse, licensed practical nurse or the therapist, if applicable, of the advanced home health aide, home health aide, or personal care aide;

(7) observations and reports made to the registered professional nurse, licensed practical nurse or therapist by the advanced home health aide, home health aide, or personal care aide, including activity sheets;

(8) documentation of accidents and incidents;

(9) documentation of the patient's receipt of information regarding his/her rights; and

(10) a discharge summary when the patient is discharged from the agency including:

(i) documentation of discharge planning preparation;

(ii) notification to the patient's authorized practitioner;

(iii) reasons for discharge and date of discharge;

(iv) summary of care given and patient's progress;

(v) patient status upon discharge including a description of any remaining needs for patient care and supportive services;

(vi) patient or family ability to self-manage in relation to any remaining problems; and

(vii) recommendations and referral for any follow-up care, if needed.

(b) Each patient's record shall be kept securely for not less than six years after discharge from the licensed home care services agency and available to the department upon request.

(c) In the case of minors, records are to be kept for not less than six years after discharge, or three years after they reach majority (18 years), whichever is the longer period.

(d) In the event that an agency discontinues operation for any reason, the governing authority, immediately preceding the discontinuance of the operation, shall make effective arrangements to maintain, store, assure access to and make available to the patient and the department upon request, all clinical records for a period consistent with the requirements of subdivisions (b) and (c) of this section. The governing authority shall notify the department in writing as to where the clinical records will be stored and how they will be made available to former patients.

(e) Each agency shall maintain written policies and procedures which:

(1) safeguard clinical records against loss or unauthorized access; and

(2) govern use, removal and release of information.


VOLUME E (Title 10)