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Title: Section 763.7 - Clinical records

Effective Date


763.7 Clinical records.

(a) The agency shall maintain a confidential clinical record for each patient admitted to care or accepted for service to include:

(1) identifying patient data;

(2) source of patient referral, including, where applicable, name and type of institution from which discharged, discharge summary and plan of care and date of discharge;

(3) medical orders and nursing diagnoses to include all diagnoses, medications, treatments, prognoses, and need for palliative care. Such orders shall be:

(i) signed by the authorized practitioner within 12 months after admission to the agency, or prior to billing, whichever is sooner;

(ii) signed by the authorized practitioner within 12 months after issuance of any change in medical orders or prior to billing, whichever is sooner, to include all written and oral changes and changes made by telephone by such practitioner; and

(iii) renewed by the authorized practitioner as frequently as indicated by the patient's condition but at least every 60 days;

(4) the comprehensive interdisciplinary patient assessment;

(5) the individualized plan of care;

(6) signed and dated progress notes, following each patient contact by each professional person providing care, which shall include a summary of patient status and response to plan of care and, if applicable, contacts with family, informal supports and other community resources, and a brief summary of care provided at the termination of each service;

(7) observations and reports made to the registered professional nurse, licensed practical nurse or supervising 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, completed by appropriate personnel when the patient is discharged from the agency, including but not limited to:

(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) In addition to meeting the clinical record requirements of subdivision (a) of this section, clinical records for long term home health care programs and AIDS home care programs shall include an evaluation of the medical, mental health, social and environmental needs of the patient, on forms prescribed by the Commissioner, which shows that the patient is medically eligible for placement in a hospital or residential health care facility were this program not available.

(c) Each patient's clinical records shall be be kept securely for not less than six years after discharge from the agency and made available to the department upon request. 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) 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.

(e)(1) For agency patients who require placement in a nursing home or health-related facility, the SCREEN as contained in section 400.12 and the Hospital/Community PRI as contained in section 400.13 of this Title shall, as appropriate, be completed by personnel qualified and trained in accordance with section 86-2.30 and section 400.12 of this Title.

(2) Each agency shall have a sufficient number of trained, qualified and approved assessors and screeners to meet H/C PRI and SCREEN requirements and to attest to the accuracy of such patient review forms.

(3) The Commissioner may waive the requirements of this subdivision or any part thereof for recognized demonstration projects to effect the development of additional knowledge and experience in different types of assessments for long term care patients.


VOLUME E (Title 10)