Ala. Admin. Code r. 420-5-17-.18

Current through Register Vol. 43, No. 1, October 31, 2024

Section 420-5-17-.18 - Medical Records

The hospice develops policies and procedures governing all aspects of the medical record.

(1)Records Shall be Confidential. When an individual enters a hospice program, records and information regarding him are confidential. Access to these records shall be limited to the patient, designated team members, physicians, others having professional responsibility, representatives of the State Board of Health, and such other persons as the patient may delegate.

(2) Each hospice care program shall establish and maintain a central clinical record for each hospice patient receiving care and services from the program and his or her family. The record shall be established and maintained in accordance with accepted principles of practice.

(3) The clinical record shall be a comprehensive compilation of information that is documented promptly for all services provided. The record shall be organized systematically to facilitate retrieval of information. Entries to the clinical record shall be made and signed by the person providing the service. All services, whether furnished by employees, persons under contract, or volunteers, shall be documented in the clinical record.

(4) Each clinical record shall contain at least the following information:

(a) Identification data.

(b) Pertinent medical history.

(c) Consent and authorization forms.

(d) Initial and subsequent assessments.

(e) The interdisciplinary plan of care.

(f) Documentation of all services and events, such as evaluations, treatments, and progress notes.

(g) The hospice care program shall provide for storage of the central clinical records to protect them against loss, destruction, and unauthorized use.

(5)Completion of Records and Centralization of Reports. Medical records of discharged patients shall be completed within 60 days. All clinical information pertaining to patient's stay is centralized in the patient's medical record.

(6)Retention and Preservation. Medical records are retained for a period of time not less than five years from date of discharge or, in the case of a minor, three years after the patient becomes of age under state law.

(7)Disposition of Medical Records. When a Hospice ceases to operate either voluntarily or by revocation of its license, the governing body (licensee) at or prior to such action shall develop a proposed plan for the storage, access and disposition of its medical records. Such plan shall be submitted in writing to the Alabama Department of Public Health for review and approval. The plan must contain provisions for proper storage, safeguarding and confidentiality, as well as access to, transfer or disposal of medical records.

Author: Jimmy D. Prince

Ala. Admin. Code r. 420-5-17-.18

New Rule: Filed August 20, 1993; effective September 23, 1993. Repealed and New Rule: Filed June 14, 2000; effective July 19, 2000.

Statutory Authority:Code of Ala. 1975, §§ 22-21-20, etseq.