Section 29-5107. RECORDS

 

5107.1Each Provider shall maintain accurate records reflecting past and current findings, the initial and subsequent plans of care, and the ongoing progress of each client.

 

5107.2Each Provider shall maintain accurate records reflecting the specific services provided to each client.

 

5107.3Each Provider shall maintain patient records that are confidential, complete and contain up-to-date information relevant to each patient's care and treatment. For purposes of record confidentiality, the disclosure of treatment information by the Provider is subject to all the provisions of applicable District and Federal Laws.

 

5107.4Each patient's record shall include written documentation of the patient's treatment needs and services. The documentation shall be written so that it is easily understood by a lay person.

 

5107.5Each patient's record shall be kept in a locked room or file maintained and safeguarded against loss or unauthorized use.

 

5107.6Each patient's record shall be available for review by MAA staff at all times.

 

5107.7Each Provider shall maintain patient records for a minimum of six (6) years.

 

5107.8Each patient's record shall include, but is not limited to, the following information:

 

(a)Medical information, including the initial and annual assessments, and the initial certification and re-certifications of the plan of care;

 

(b)General information including each patient's name, Medicaid identification number, address, telephone number, age, sex, name and telephone of emergency contact person, physician's name, address and telephone number;

 

(c)Description and dates of services rendered, including the name of the home health aide performing the services;

 

(d)Documentation of each supervisory visit of the registered nurse or therapist, including signed and dated clinical progress notes;

 

(e)Extended authorizations for services;

 

(f)Discharge summary, if applicable; and

 

(g)Any other appropriate identifying information that is pertinent to patient care.

 

source

Final Rulemaking published at 50 DCR 3957 (May 23, 2003).