La. Admin. Code tit. 48 § I-9129

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

Section I-9129 - Clinical Records

A. Requirements. A clinical record containing past and current findings shall be maintained either electronically or in paper form for every patient who is accepted by the agency for home health service and shall be accessible to authorized agency staff as needed. In addition, the agency shall comply with the following requirements for clinical records.

1. The information contained in the clinical record shall be accurate and immediately available to the patient's authorized healthcare provider and appropriate HHA staff. The record may be maintained electronically.

2. All entries shall be legible, clear, complete, and appropriately authenticated and dated. Authentication shall include signatures or a secured computer entry with the unique identifier of a primary author who has reviewed and approved the entry.

3. The original clinical records of active patients may be kept in the branch office for the convenience of the staff providing services. The records of patients whose services are provided by parent office staff shall be kept in that office.

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

5. A signed consent for treatment form shall be obtained from the patient and/or the patient's family and retained in the record.

6. When applicable, a signed release of information form shall be obtained from the patient and/or the patient's family and a copy shall be retained in the record.

7. Records maintained either in paper or electronically shall be made available to LDH staff upon request.

8. Records shall be retained either electronically or in paper form for a period of not less than six years from the date on which the record was established and, if there is an audit or litigation that involves the records, the timeframe may be extended.

9. The agency shall have internal policies that provide for the retention of clinical records even if the agency discontinues operation.

10. Repealed.

11. Repealed.

B. Clinical Note. A clinical note shall be legibly written by the person making the visit and incorporated into the clinical record within one week of the visit. A patient care clinical note shall be completed on each visit and shall contain the following, at a minimum:

1. the date of the visit;

2. time of arrival;

3. time of exit;

4. services rendered and/or justification for the visit;

5. signature of the person making the visit;

6. vital signs, according to authorized healthcare provider's order or accepted standards of practice; and

7. comments when indicated.

NOTE: The patient or a responsible person shall sign the permanent record of visit that is retained by the agency. However, it is not necessary for the patient or a responsible person to sign on the clinical note.

C. Clinical Record Contents. An active clinical record shall contain all of the following documentation:

1. the initial assessment;

2. the current POC signed and dated by the authorized healthcare provider.

3. the current comprehensive assessment;

4. the current clinical notes for at least the past 60 days, including a description of measurable outcomes relative to the goals in the POC that have been achieved;

5. identifying data, including:

a. name;

b. address;

c. date of birth;

d. gender;

e. agency case number; and

f. next of kin;

6. the date that care started;

7. attending authorized healthcare provider data, including:

a. name;

b. address; and

c. telephone number;

8. the diagnoses, including all conditions relevant to the current POC;

9. the types of services rendered, including frequency, duration and the applicable clinical notes;

10. a list of current medications indicating the drug, dosage, frequency, route of administration if other than oral, dates that a drug was initiated and discontinued, drug allergies, dates that non-prescription remedies were initiated and discontinued, side effects and a tracking procedure, and any adverse reactions experienced by the patient;

11. the current medical orders;

12. diet;

13. functional status;

14. rehabilitation potential;

15. the prognosis;

16. durable medical equipment available and/or needed;

17. when applicable, a copy of the transfer form that was forwarded to the appropriate health care facility that shall be assuming responsibility for the patient's care; and

18. the discharge summary.

La. Admin. Code tit. 48, § I-9129

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 18:57 (January 1992), amended LR 21:177 (February 1995), amended LR 22:1135 (November 1996), LR 27:2252 (December 2001), Amended by the Department of Health, Bureau of Health Services Financing, LR 481841 (7/1/2022).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and R.S. 40:2116.31 et seq.