.12 Clinical Records.

A. A clinical record shall be maintained for each patient in accordance with accepted professional standards, including, at a minimum:

(1) All pertinent diagnoses;

(2) Name, address, and telephone number of physicians;

(3) Physician's orders, including specific instructions for services to be rendered, activities and limitations, and medically-necessary supplies and equipment;

(4) Drug information, including type, dosage, route of administration, frequency, and history of sensitivities or allergic reactions;

(5) Nutritional requirements, including specific dietary plans;

(6) Prognosis, including rehabilitation potential;

(7) Patient care plans, which should include:

(a) Long and short-range goals;

(b) Physical needs, including safety measures to protect against injury;

(c) Psycho-social needs;

(d) Actions taken by individual disciplines; and

(e) Evidence of periodic reappraisal of the needs of the patient;

(8) Progress notes and modifications to the treatment plan; and

(9) Discharge summary.

B. The home health agency should maintain a unit record for all patients receiving multi-disciplinary care.

C. All notes and reports entered in the clinic record shall be typewritten or written in ink, legible, dated and signed with the name and title of the person rendering service.

D. The home health agency shall establish and implement policies concerning clinical records which assure:

(1) That records of discharged patients are completed no later than 30 days after the date of discharge;

(2) The proper operation of a system for identifying, filing, and retrieving clinical records;

(3) Proper mechanisms for the timely transfer of clinical record information upon request from duly-authorized persons and organizations;

(4) Proper safeguards for clinical record information against loss, destruction, or illegal or unauthorized use;

(5) That clinical records are preserved for at least 5 years from the date of discharge;

(6) That, with the approval of the Department, provisions are made for retention of clinical records when it ceases operation; and

(7) That progress notes are recorded within 5 working days after service is delivered. The treatment plan shall be modified accordingly.

E. A home health agency which provides maintenance health care or in-home services, or both, may not be required to maintain the same level of supervisory and record-keeping requirements of these regulations for those patients who only receive the maintenance health or in-home services. In these cases, the agency shall develop performance criteria, supervisory and record-keeping requirements for these patients.