Okla. Admin. Code § 310:661-3-3.1

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

Section 310:661-3-3.1 - Clinical records

(a)General. A clinical record containing past and current findings is maintained for each hospice patient. The clinical record contains accurate clinical information that is available to the patient's attending physician and hospice staff. The clinical record may be maintained electronically.

(b)Content. Each patient's record must include the following:

(1) The initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes;

(2) Signed copies of the notice of patient rights;

(3) Responses to medications, symptom management, treatments, and services;

(4) Outcome measure data elements, as described in 310:661-5-3.1;

(5) Physician certification of terminal illness;

(6) Any advance directives; and

(7) Physician orders.

(c)Authentication. All entries must be legible, clear, complete, and appropriately authenticated and dated in accordance with hospice policy.

(d)Protection of information. The clinical record, its contents and the information contained therein must be safeguarded against loss or unauthorized use. Additionally, the hospice is subject to all Federal and State privacy laws.

(e)Discharge or transfer of care.

(1) If the care of a patient is transferred to another licensed hospice, the hospice will forward to the receiving hospice within twenty-four (24) hours, a copy of:

(A) The hospice discharge summary; and

(B) The patient's clinical record, as requested.

(2) If a patient revokes the election of hospice care, or is discharged from hospice, the hospice will forward to the patient's attending physician within twenty-four (24) hours, a copy of:

(A) The hospice discharge summary; and

(B) The patient's clinical record, if requested.

(3) The hospice discharge summary as required above must include:

(A) A summary of the patient's stay including treatments, symptoms and pain management;

(B) The patient's current plan of care;

(C) The patient's current physician orders; and

(D) Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving hospice.

(f)Retrieval of clinical records. The clinical record, whether hard copy or in electronic form, must be made readily available on request.

Okla. Admin. Code § 310:661-3-3.1

Added at 26 Ok Reg 2042, eff 6-25-09

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