3701-19-50 Clinical record.

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

(1) The pediatric respite care program shall maintain the records and reports for seven years following the date of the pediatric respite care patient's discharge, except if the resident is a minor, the records shall be maintained for three years past the age of majority but not less than seven years.

(2) Upon closure of the pediatric respite care program facility, the operator shall provide and arrange for the retention of records and reports in a secured manner for not less than seven years. The pediatric respite care program shall notify the director of the location where the records will be stored.

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

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

(1) Identification data;

(2) Pertinent medical history, including the physician's diagnosis of a life-threatening disease or condition;

(3) Consent and authorization forms;

(4) Initial and subsequent assessments that include evaluations of the psychological, psychosocial, and spritiual needs, if any, of the patient as well as the need for bereavement or volunteer services;

(5) The interdisciplinary plan of care;

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

(7) Transfer and discharge summaries.

(D) The pediatric respite care program shall provide for storage of the 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 pediatric respite 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: 12/26/2013
R.C. 119.032 review dates: 12/01/2018
Promulgated Under: 119.03
Statutory Authority: 3712.031
Rule Amplifies: 3712.031 , 3712.041 , 3712.051 , 3712.061 , 3712.09 , 3712.99