Section 22-B3911. CLINICAL RECORDS

 

3911.1Each home care agency shall establish and maintain a complete, accurate, and permanent clinical record of the services provided to each patient in accordance with this section and accepted professional standards and practices.

 

3911.2Each clinical record shall include the following information related to the patient:

 

(a)Admission data, including name, address, date of application, date of birth, sex, agency case number, next of kin or responsible party, date accepted by the agency to receive services, and source of payment, if applicable;

 

(b)Source of referral, including date of discharge if from a hospital or extended care facility;

 

(c)Initial assessment and on-going evaluation;

 

(d)Plan of care for each service provided;

 

(e)Physician's orders;

 

(f)History of sensitivities and allergies;

 

(g)Medication sheet;

 

(h)Clinical, progress, and summary notes, and activity records, signed and dated as appropriate by professional and direct care staff;

 

(i)Documentation of supervision of home care services;

 

(j)Documentation of discharge planning, if appropriate;

 

(k)Discharge summary, including the reason for termination of services and the effective date of discharge;

 

(l)Documentation of coordination of services, if applicable;

 

(m)Type and frequency of diagnostic services;

 

(n)Type of medical equipment used by the patient;

 

(o)Dates and times of collection of specimens;

 

(p)Results of diagnostic services and dates of reporting;

 

(q)Communications between the agency and all health care professionals involved in the patient's care;

 

(r)Documentation of consent for specialized services; and

 

(s)Documentation of training and education given to the patient and the patient's caregivers.

 

source

Final Rulemaking published at 51 DCR 2876 (March 19, 2004).