Statutes, codes, and regulations
California Code Of Regulations
Title 22 - Social SecurityDivision 5 - Licensing and Certification of Health Facilities, Home Health Agencies, Clinics, and Referral AgenciesChapter 6 - Home Health Agencies
Article 4 - Administration
Section 74735 - Patient Health Records

Cal. Code Regs. tit. 22 § 74735

Download
PDF
Current through Register 2024 Notice Reg. No. 45, November 8, 2024
Section 74735 - Patient Health Records
(a) The agency shall establish and maintain for each patient accepted for care a health record which shall include the following information:
(1) Admission record. The admission record shall include:
(A) Name.
(B) Current address.
(C) Date of birth.
(D) Sex.
(E) Date of admission.
(F) Name, address and telephone number of the responsible party.
(G) Name, address, and telephone number of the attending physician, dentist, podiatrist, or other licensed and legally authorized person whose orders or recommendations are being implemented by the home health agency.
(H) Admission diagnosis or pertinent health information.
(I) Reason for admission.
(2) Notation of the conditions and diagnoses which are relevant to the plan of treatment, plan of care, or plan for personal care services.
(3) Plan of treatment, plan of care, or plan for personal care services in its entirety as specified in Section 74697.
(4) Allergies and known untoward reactions to drugs and food. This information shall be given such prominence in the record that it is obvious to any health practitioner or agency personnel who have reasons to provide food or medication to the patient.
(5) Clinical notes dictated or written at the time of service by personnel rendering the services. Clinical notes shall be signed and incorporated into the patient's health record at least every seven working days.
(6) Laboratory and X-ray reports, if applicable.
(7) Treatment consent or service authorization forms.
(8) Documentation that a list of patient rights has been made available to each patient, patient's representative, or next of kin.
(9) Discharge statement. The discharge statement shall include the date of discharge, reason for termination of services, and condition upon discharge.

Cal. Code Regs. Tit. 22, § 74735

1. Amendment of section heading, section and NOTE filed 4-28-95 as an emergency; operative 4-28-95 (Register 95, No. 17). A Certificate of Compliance must be transmitted to OAL by 8-28-95 or emergency language will be repealed by operation of law on the following day.
2. Amendment of section heading, section and NOTE refiled 8-14-95 as an emergency; operative 8-14-95 (Register 95, No. 33). A Certificate of Compliance must be transmitted to OAL by 12-12-95 or emergency language will be repealed by operation of law on the following day.
3. Amendment of section heading, section and NOTE refiled 12-12-95 as an emergency; operative 12-12-95 (Register 95, No. 50). A Certificate of Compliance must be transmitted to OAL by 4-10-96 or emergency language will be repealed by operation of law on the following day.
4. Amendment of section heading, section and NOTE filed 4-11-96 as an emergency; operative 4-11-96 (Register 96, No. 15). A Certificate of Compliance must be transmitted to OAL by 8-9-96 or emergency language will be repealed by operation of law on the following day.
5. Certificate of Compliance as to 4-28-95 order transmitted to OAL 8-7-96 and disapproved 9-19-96 (Register 96, No. 38).
6. Amendment of section heading, section and NOTE filed 9-19-96 as an emergency; operative 9-19-96 (Register 96, No. 38). A Certificate of Compliance must be transmitted to OAL by 1-17-97 or emergency language will be repealed by operation of law on the following day.
7. Editorial correction of HISTORY 6 (Register 97, No. 3).
8. Amendment of section heading, section and NOTE refiled 1-16-97 as an emergency; operative 1-16-97 (Register 97, No. 3). A Certificate of Compliance must be transmitted to OAL by 5-16-97 or emergency language will be repealed by operation of law on the following day.
9. Amendment of section heading, section and NOTE refiled 5-15-97 as an emergency; operative 5-15-97 (Register 97, No. 20). A Certificate of Compliance must be transmitted to OAL by 9-12-97 or emergency language will be repealed by operation of law on the following day.
10. Certificate of Compliance as to 5-15-97 order, including amendment of section and NOTE, transmitted to OAL 8-26-97 and filed 10-8-97 (Register 97, No. 41).

Note: Authority cited: Sections 1734 and 100275, Health and Safety Code. Reference: Sections 1727.5 and 1734, Health and Safety Code.

1. Amendment of section heading, section and Note filed 4-28-95 as an emergency; operative 4-28-95 (Register 95, No. 17). A Certificate of Compliance must be transmitted to OAL by 8-28-95 or emergency language will be repealed by operation of law on the following day.
2. Amendment of section heading, section and Note refiled 8-14-95 as an emergency; operative 8-14-95 (Register 95, No. 33). A Certificate of Compliance must be transmitted to OAL by 12-12-95 or emergency language will be repealed by operation of law on the following day.
3. Amendment of section heading, section and Note refiled 12-12-95 as an emergency; operative 12-12-95 (Register 95, No. 50). A Certificate of Compliance must be transmitted to OAL by 4-10-96 or emergency language will be repealed by operation of law on the following day.
4. Amendment of section heading, section and Note filed 4-11-96 as an emergency; operative 4-11-96 (Register 96, No. 15). A Certificate of Compliance must be transmitted to OAL by 8-9-96 or emergency language will be repealed by operation of law on the following day.
5. Certificate of Compliance as to 4-28-95 order transmitted to OAL 8-7-96 and disapproved 9-19-96 (Register 96, No. 38).
6. Amendment of section heading, section and Note filed 9-19-96 as an emergency; operative 9-19-96 (Register 96, No. 38). A Certificate of Compliance must be transmitted to OAL by 1-17-97 or emergency language will be repealed by operation of law on the following day.
7. Editorial correction of History 6 (Register 97, No. 3).
8. Amendment of section heading, section and Note refiled 1-16-97 as an emergency; operative 1-16-97 (Register 97, No. 3). A Certificate of Compliance must be transmitted to OAL by 5-16-97 or emergency language will be repealed by operation of law on the following day.
9. Amendment of section heading, section and Note refiled 5-15-97 as an emergency; operative 5-15-97 (Register 97, No. 20). A Certificate of Compliance must be transmitted to OAL by 9-12-97 or emergency language will be repealed by operation of law on the following day.
10. Certificate of Compliance as to 5-15-97 order, including amendment of section and Note, transmitted to OAL 8-26-97 and filed 10-8-97 (Register 97, No. 41).