Section R432-750-9 - Patient Records(1) The administrator shall develop and implement record keeping policies and procedures that address the use of patient records by authorized staff, content, confidentiality, retention, and storage. (a) The licensee shall ensure that records are organized in a uniform medical record format.(b) The licensee shall maintain an identification system to facilitate location of each patient's current or closed record.(c) The licensee shall maintain an accurate, current record for each patient receiving service.(d) Each licensee who has a patient contact or provides a service shall insure that a clinical note entry of that contact or service is made in the patient's record.(e) Any entries shall be dated and authenticated with the signature and title of the person making the entry.(f) The licensee shall document each service provided and the outcome of each service in the individual patient record.(2) The licensee shall ensure that signed and dated physician's orders are incorporated into the plan of care and renewed at least every 90 days. A copy of the order is acceptable as long as the original order is available on request.(3) The licensee shall ensure that each patient record shall contain at least the following information:(a) demographic information that includes:(iv) patient date of birth;(v) name and address of nearest relative or responsible person;(vi) name and telephone number of the physician with primary responsibility for patient care; and(vii) name and telephone number of the person or family member who, in addition to agency staff, provides care in the place of residence;(c) pertinent medical and surgical history if available;(d) a written and signed informed consent to receive hospice services;(e) orders by the attending physician for hospice services;(f) medications and treatments as applicable;(g) a written plan of care; and(h) a signed, dated patient assessment that includes the following: (i) a description of the patient's functional limitations;(ii) a physical assessment noting chronic or acute pain and other physical symptoms and their management;(iii) a psychosocial assessment of the patient and family;(iv) a spiritual assessment; and(v) a written summary report of hospice services provided that is additionally sent to the patient's attending physician at least every 90 days.(4) The person who is assigned to supervise or coordinate care for a patient shall complete a discharge summary when services to the patient are terminated. The discharge summary shall include the reason for discharge and the name of the facility or agency if the patient is referred or transferred.(5) The licensee shall safeguard clinical record information against loss, destruction, and unauthorized use.(a) The licensee shall ensure that written procedures govern the use and removal of records and conditions for release of patient information.(b) A written consent is required for the release of patient information and photographing recorded information.(c) When a patient is transferred to another facility or agency, the licensee shall send a copy of the record or abstract to that service agency.(6) The licensee shall provide an accessible area for filing and safe storage of medical records. (a) The licensee shall ensure that each patient record is retained for at least seven years after the last date of patient care.(b) The licensee shall transfer any patient records to a new owner upon a change of agency ownership.Utah Admin. Code R432-750-9
Amended by Utah State Bulletin Number 2023-10, effective 5/5/2023