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Title: Section 794.4 - Clinical record

Effective Date


794.4 Clinical record. The governing authority shall ensure that:  

(a) there is a standardized clinical record system which is maintained in conformance with generally accepted medical record practices; 

(b) a clinical record containing past and current findings is maintained for each hospice patient. The clinical record must contain correct clinical information that is available to the patient's attending physician and hospice staff including:  

(1) initial assessment, comprehensive assessments and updated comprehensive assessments; 

(2) initial plan of care and updated plans of care;  

(3) clinical notes. A clinical note means a notation of a contact with the patient and/or the family that is written and dated by any person providing services and that describes signs and symptoms, treatments and medications administered, including the patient's reaction and/or response, any changes in physical, emotional, psychosocial or spiritual condition during a given period of time;  

(4) signed copies of the notice of patient rights pursuant to section 793.1 of this Title and election statement pursuant to section 793.2 of this Title; 

(5) responses to medications, symptom management, treatments and services;  

(6) outcome measure data elements; 

(7) physician certification and recertification of terminal illness;  

(8) any advance directive; 

(9) physician orders;  

(10) documentation regarding instructions and written information provided to patients and families on the use, management and disposal of controlled substances and durable medical equipment and supplies; and  

(11) a discharge summary if the patient is discharged from hospice, completed by appropriate personnel, including but not limited to:  

(i) reason for discharge and date; 

(ii) a summary of the hospice care given including treatments, symptoms and pain management; and 

(iii) patient status upon discharge including a description of any remaining needs. 

(c) the clinical record for each patient is in a form that can be summarized for transferral of information for inpatient care, home care services, and bereavement services, as appropriate; 

(d) the clinical record meets the following requirements as applicable: 

(1) all entries shall be current;  

(2) all entries shall be legible and recorded in dark ink to facilitate photocopying;  

(3) all entries shall be signed and dated, including the time of day and authenticated; and  

(4) all records shall be kept in a place convenient to and easily retrievable by the hospice staff; 

(e) the clinical record, whether hard copy or in electronic form, is readily available on request by an appropriate authority; 

(f) the clinical record, its contents and the information contained is safeguarded against loss or unauthorized use. The hospice must be in compliance with state and federal requirements, including section 18 of the Public Health Law, governing the disclosure of personal health information.  

(g) each patient’s clinical record shall be retained by the hospice for at least a six-year period after death or discharge from the hospice. In the case of a minor who is discharged from the hospice, clinical records shall be retained for at least a six-year period after death or discharge or, if the minor attains majority (18 years), for a three-year period thereafter, whichever period is longer. 


VOLUME E (Title 10)