Okla. Admin. Code § 310:661-3-3

Current through Vol. 42, No. 4, November 1, 2024

Section 310:661-3-3 - Medical records

(a) The hospice must establish and maintain a medical record for each individual receiving care and services. The record must be complete, timely and accurately documented, and readily accessible.

(b) The medical record must contain sufficient information to justify the diagnosis and warrant the treatment and services provided. Entries are made and signed by the person providing the services. The record must include all care and services whether furnished directly or under arrangements by the hospice. Each record must contain at least the following:

(1) Identification data;

(2) Initial and subsequent assessments;

(3) Plan of care;

(4) Consent, authorization and election forms;

(5) Medical history; and

(6) Complete documentation of all care, services and events including evaluations, treatments, progress notes, laboratory and x-ray reports, and discharge summary.

(c) The hospice must safeguard the medical record against loss, destruction, and unauthorized use.

(d) Current records must be completed promptly. A plan of care must be completed within forty-eight (48) hours following admission. Records of discharged patients must be completed within thirty (30) days following discharge.

(e) Medical records must be retained at least five (5) years beyond the date the patient was last seen or at least three (3) years beyond the date of the patient's death.

(f) A hospice may microfilm medical records in order to conserve space. Records reconstituted from microfilm will be considered the same as the original and retention of the microfilmed record constitutes compliance with preservation laws.

(g) The hospice must advise the Department in writing at the time of cessation of operation as to where hospice records will be archived and how these records can be accessed.

Okla. Admin. Code § 310:661-3-3

Added at 9 Ok Reg 1985, eff 6-11-92; Amended at 14 Ok Reg 2106, eff 4-7-97 (emergency); Amended at 14 Ok Reg 2269, eff 6-12-97

Amended by Oklahoma Register, Volume 39, Issue 24, September 1, 2022, eff. 9/11/2022