Current through Register Vol. 54, No. 45, November 9, 2024
Section 601.36 - Clinical records(a)Maintenance and content of records. A clinical record containing pertinent past and current findings in accordance with accepted professional standards shall be maintained for every patient receiving home health care services. In addition to the plan of treatment-see § 601.31(b) (relating to acceptance of patients, plan of treatment and medical supervision)-the record shall contain appropriate identifying information; name of physician; drug and dietary treatment; activity orders; signed and dated clinical and progress notes by the individual who delivered the service-clinical notes are written the day service is rendered and incorporated into the clinical record no less often than weekly; copies of summary reports sent to the physician; and a discharge summary.(b)Retention of records. Clinical records shall be retained for 7 years after discharge of the patient. Policies shall provide for retention even if the home health care agency discontinues operations. If the patient is transferred to another home health care agency, a copy of the record or abstract shall accompany the patient.(c)Protection of records. Information contained in the patient's record shall be privileged and confidential. Clinical record information shall be safeguarded against loss or unauthorized use. Written procedures shall govern use and removal of records and conditions for release of information. The patient's written consent shall be required for release of information outside the home health care agency, except as otherwise provided by law or third-party contractual arrangements.