R432-750-12. Patient Records

  (1) The administrator shall develop and implement record keeping policies and procedures that address the use of patient records by authorized staff, content, confidentiality, retention, and storage.

  (a) Records shall be organized in a uniform medical record format.

  (b) The agency shall maintain an identification system to facilitate location of each patient's current or closed record.

  (c) The hospice shall maintain an accurate, up-to-date record for every patient receiving service.

  (d) Each hospice health care provider who has patient contact or provides a service shall insure that a clinical note entry of that contact or service is made in the patient's record.

  (e) All entries must be dated and authenticated with the signature and title of the person making the entry.

  (f) The hospice must document services provided and outcomes of these services in the individual patient record.

  (2) Physician's orders shall be incorporated into the plan of care and renewed at least every 90 days.

  (a) The orders shall include the physician signature and date.

  (b) Orders faxed from the physician are acceptable provided that the original order is available upon request.

  (3) Each patient's record shall contain at least the following information:

  (a) demographic information including patient's name, address, age, date of birth, name and address of nearest relative or responsible person, name and telephone number of physician with primary responsibility for patient care, and if applicable, the name and telephone number of the person or family member who, in addition to agency staff, provides care in the place of residence;

  (b) diagnosis;

  (c) pertinent medical and surgical history if available;

  (d) a written and signed informed consent to receive hospice services;

  (e) orders by the attending physician for hospice services;

  (f) medications and treatments as applicable;

  (g) a written plan of care; and

  (h) a signed, dated patient assessment which includes the following:

  (i) a description of the patient's functional limitations;

  (ii) a physical assessment noting chronic or acute pain and other physical symptoms and their management;

  (iii) a psychosocial assessment of the patient and family;

  (iv) a spiritual assessment; and

  (v) a written summary report of hospice services provided.

  (4) The hospice must send a copy of the summary required in subsection 12(3)(h)(v) to the patient's attending physician at least every 90 days. The summary shall become part of the patient's and family record as applicable.

  (5) The person who is assigned to supervise or coordinate care for a patient must complete a discharge summary when services to the patient are terminated. The summary shall include:

  (a) the reason for discharge; and

  (b) the name of the facility or agency if the patient has been referred or transferred.

  (6) The hospice shall safeguard clinical record information against loss, destruction, and unauthorized use.

  (a) Written procedures shall govern the use and removal of records and conditions for release of patient information.

  (b) A written consent is required for the release of patient/client information and photographing of recorded information.

  (c) When a patient is transferred to another facility or agency, a copy of the record or abstract must be sent to that service agency.

  (7) The agency shall provide an accessible area for filing and safe storage of medical records.

  (a) Patient records shall be retained for at least seven years after the last date of patient care.

  (b) Upon change of ownership, all patient records shall be transferred to new owners.