6 Colo. Code Regs. § 1011-1-21-9
Current through Register Vol. 47, No. 11, June 10, 2024
Section 6 CCR 1011-1-21-9 - CLINICAL RECORDS9.1 The hospice shall maintain a centralized and complete record on every individual receiving service in accordance with accepted principles of medical record practice.9.2 The record shall include documentation of all services provided whether furnished directly or by contract.9.3 Each record shall include but not be limited to:(A) Identification and demographic data;(B) The initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes;(C) History of terminal illness and other related conditions;(D) Documentation of all services and responses to treatments and interventions including lists of current medications and medication administration records (if applicable);(E) Signed consents, authorizations, and advance directives;(F) Orders from licensed providers with prescriptive authority and/or other licensed or qualified health care professionals, and(G) Discharge/transfer records.9.4 All entries shall be completed in a manner that is legible and permanent; dated and authenticated in accordance with hospice policy and currently accepted standards of practice.9.5 Hospice shall ensure the privacy, security and safety of the records against loss, destruction or unauthorized use, including compliance with protected health information in compliance with federal and state law.9.6 All records shall be maintained for a period of six (6) years after death or discharge. In the case of a minor, the record shall be maintained for a period of six (6) years after death or for six years after the minor attains majority (18 years old).9.7 If the hospice discontinues operation, hospice policies shall provide for retention and storage of clinical records according to state and federal law. The hospice shall inform the State licensing agency where such clinical records will be stored and how they may be accessed.9.8 The clinical record, whether hard copy or in electronic form, shall be made readily available on request by an appropriate authority.