S.C. Code Regs. § § 61-77.700.701

Current through Register Vol. 48, 12, December 27, 2024

Section 61-77.700.701 - Content (II)

A. The Home Health Agency shall maintain an organized record for each Patient. The Home Health Agency shall ensure all entries in the Patient record are permanently written, typed, or electronic media, authenticated by the author, and dated.

B. The Home Health Agency shall ensure Patient records reflect services, treatment, and care provided directly to the Patient by the Home Health Agency or by the Contracted Party, including Patient progress, and descriptions of the planned clinical outcomes achieved.

C. The Home Health Agency shall ensure the specific Patient record entries and documentation include, at a minimum:

1. Face sheet;

a. Basic identification information;

b. Diagnosis;

c. Primary care Physician's name and phone number;

d. Representative's name, or name of other individual to be contacted in case of emergency, and phone number;

e. Patient's address and phone number;

f. Admission date; and

g. Start of Care Date;

2. Comprehensive Assessment;

3. Original Treatment Plan and subsequent reviews and changes;

4. Clinical notes including all interventions, medication administration, treatments, and services, and responses to those interventions;

5. Physician or other Authorized Healthcare Provider orders; and

6. Signed and dated original Informed Consent.

S.C. Code Regs. § 61-77.700.701

Added by State Register Volume 46, Issue No. 05, eff. 5/27/2022.