3701-19-23 Central clinical record.

(A) Each hospice care program shall establish and maintain a central clinical record for each hospice patient receiving care and services from the program and his or her family. The record shall be established and maintained in accordance with accepted standards of practice.

(B) The clinical record shall be a comprehensive compilation of information that is documented promptly for all services provided. The record shall be organized systematically to facilitate retrieval of information. Entries to the clinical record shall be made and signed by the person providing the service. All services, whether furnished by employees, persons under contract, or volunteers, shall be documented in the clinical record.

Interpretive guideline: entries in the clinical record shall be dated and shall be made within a reasonable period of time after the services are provided, which is recommended to be not more than twenty-one days or within other acceptable written standards of practice guidelines.

(C) Each clinical record shall contain at least the following information:

(1) Identification data;

(2) Pertinent medical history, including the physician's diagnosis of terminal illness;

(3) Consent and authorization forms;

(4) Initial and subsequent assessments.

Interpretive guideline: the assessments should include evaluations of physical, psychosocial, and spiritual needs and the need for volunteer and bereavement services;

(5) The interdisciplinary plan of care;

(6) Documentation of all services and events, such as evaluations, treatments, and progress notes;

(7) A statement of whether or not the patient, if an adult, has prepared an advanced directive. "Advanced directive" has the same meaning as "declaration" as defined in section 2133.01 of the Revised Code; and

(8) Transfer and discharge summaries.

(D) The hospice care program shall provide for storage of the central clinical records to protect them against loss, destruction, and unauthorized use. The program also shall have policies and procedures to ensure the confidentiality of records.

(E) A hospice care program which maintains a patient's clinical record electronically shall use an electronic signature system that meets the requirements specified under division (B) of section 3701.75 of the Revised Code. Electronic patient clinical records shall be accessible to the director during inspections.

Effective: 08/23/2009
R.C. 119.032 review dates: 05/19/2009 and 08/15/2014
Promulgated Under: 119.03
Statutory Authority: 3712.03
Rule Amplifies: 3712.01 , 3712.03 , 3712.06
Prior Effective Dates: 12/31/1990, 10/17/99