Section 33-03-10.1-16 - Clinical record services An agency shall maintain clinical records for each patient and provide relevant information from these clinical records to the personnel providing services in the patient's home.
1. The clinical record must contain sufficient information to identify the patient clearly, to justify the diagnosis and treatment, and to document the results of treatment accurately. All clinical records must contain at least the following general categories of data: a. Identification data and consent forms; b. The name, address, and phone number of the patient's physician; c. The physician's signed order for therapeutic services and the approved plan of care, which must include, when appropriate to the services being provided: d. Initial and periodic assessments and care plans by professionals providing services; e. Signed and dated admission, observation, progress, clinical and supervisory notes, and other information necessary to document services are provided and not just offered; f. Copies of summary reports sent to the physician; g. Diagnostic and therapeutic orders signed by the physician; h. Reports of treatment and clinical findings;i. Transfer form, if applicable; and2. All clinical information pertaining to the patient's care must be maintained in a centralized location by the parent or branch office. 3. Clinical records of services provided must be kept in ink, typed, or electronic data systems. 4. Entries into the clinical record for services rendered must be written within twenty-four hours and incorporated into the clinical record in a timeframe specified by agency policy. 5. Entries must be made by the person providing services, must contain a statement of facts personally observed, and must be signed and dated. Initials may be used in the clinical record if the full name has been identified in another location in the record. 6. Verbal orders from a physician must be signed and incorporated into the clinical record in a timeframe consistent with agency policy. 7. Clinical records must be safeguarded against loss or unauthorized use. Written policies and procedures must be in place regarding the use and removal of records and the conditions for release of information. The patient's or legal representative's written consent must be required for release of information not authorized by statute. 8. Clinical records must be maintained consistent with acceptable professional guidelines. 9. Retention of patient records must be as follows: a. Patient records of discharged patients must be preserved for a period of ten years from the date of discharge. Records of deceased patients must be preserved seven years. b. In the case of minors, records must be retained for the period of minority and ten years from the date of live discharge. Records of deceased patients who are minors must be preserved for the period of minority and seven years. N.D. Admin Code 33-03-10.1-16
Effective January 1, 1998.General Authority: NDCC 23-01-04, 23-17.3-08
Law Implemented: NDCC 23-17.3-05, 23-17.3-08