La. Admin. Code tit. 48 § I-8233

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-8233 - Clinical Records

A. In accordance with accepted principles of practice the hospice shall establish and maintain a clinical record (either hard copy or electronic) for every individual receiving care and services. The record shall be complete, promptly and accurately documented, legible, readily accessible and systematically organized to facilitate retrieval. The clinical record shall contain all pertinent past and current medical, nursing, social, and other therapeutic information, including the current POC under which services are being delivered.

B. Hospice records shall be maintained in a distinct location and not mingled with records of other types of health care related agencies.

C. Original clinical records shall be kept in a safe and confidential area which provides convenient access to clinicians.

D. The agency shall have policies addressing who is permitted access to the clinical records. No unauthorized person shall be permitted access to the clinical records.

E. All clinical records shall be safeguarded against loss, destruction and unauthorized use.

F. Records shall be maintained for six years from the date of discharge, unless there is an audit or litigation affecting the records. Records for individuals under the age of majority shall be kept in accordance with current state and federal law.

G. When applicable, the agency will obtain a signed "release of information" from the patient and/or the patient's family; a copy will be retained in the record.

H. The clinical record shall contain a comprehensive compilation of information including, but not limited to, the following:

1. initial and subsequent Plans of Care and initial assessment;

2. certifications of terminal illness;

3. written orders for admission and changes to the POC;

4. current clinical notes (at least the past 60 days);

5. Plan of Care;

6. signed consent, authorization and election forms;

7. pertinent medical history; and

8. identifying data, including name, address, date of birth, sex, agency case number; and next of kin.

I. Entries are made for all services provided and are signed by the staff providing the service.

J. Complete documentation of all services and events (including evaluations, treatments, progress notes, etc.) are recorded whether furnished directly by hospice staff or by arrangement.

K. The agency may produce, maintain and store records either in paper documentation form or in electronic form. Records stored in electronic form shall be password protected.

La. Admin. Code tit. 48, § I-8233

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing LR 15:482 (June 1989), amended LR 24:2270 (December 1998), Amended by the Department of Health, Bureau of Health Services Financing, LR 44600 (3/1/2018).

AUTHORITY NOTE: Promulgated in accordance with R.S. 40:2181-2191.