10.07.05.14

.14 Clinical Records.

A. With the exception of §B of this regulation, an agency shall ensure that a clinical record is maintained for each client in a manner that ensures security and confidentiality, and includes at a minimum:

(1) The documentation required by §D of this regulation;

(2) Any currently effective health care orders;

(3) Nurse’s assessment

(4) Rehabilitation plans, if appropriate;

(5) The care plan;

(6) Medications administered or taken, including:

(a) Dosage;

(b) Route of administration; and

(c) Frequency;

(7) History of sensitivities or allergic reactions;

(8) Nutritional requirements, including specific dietary plans;

(9) Medically necessary supplies and equipment;

(10) Care notes;

(11) The name, address, and telephone number of:

(a) The client’s physicians; and

(b) The client representative; and

(12) The following documents for each client upon discharge:

(a) Directions for the safe continuation of care after discharge; and

(b) If skilled services have been provided, a discharge summary that includes the reason for discharge.

B. An agency that provides care to clients who are assessed as not requiring certified caregivers or skilled services shall maintain a client record, including but not limited to:

(1) Nursing assessment;

(2) Plan of care;

(3) Services provided;

(4) Any significant change of condition; and

(5) Any other pertinent information regarding the client being served.

C. An agency shall develop policies and procedures to ensure that all information relating to a client’s condition or preferences, including any significant change of condition as defined in Regulation .02B(27) of this chapter, is documented in the client’s record and communicated in a timely manner to:

(1) The client;

(2) The client representative, if appropriate; and

(3) All appropriate health care professionals and staff who are involved in the development and implementation of the client’s care plan.

D. Care Notes.

(1) Appropriate staff shall write care notes for each client, at a minimum:

(a) On admission and at least weekly;

(b) Upon any significant changes in the client’s condition; and

(c) When the care plan is modified.

(2) The agency shall ensure that all notes and reports that are entered in the clinical record, which may include an electronic record, are detailed, legible, chronological, dated, and signed with the name and title of the individual rendering the service.

E. The agency may accept orders for care with an electronic signature. Orders may be received by, but not limited to, mail, hand delivery, or facsimile transmission.