Conn. Agencies Regs. § 19-13-D88 - Patient records

(a) An agency shall maintain a patient record system which includes, but is not limited to:

(1) A written policy on the protection of records which defines procedures governing the use and removal of records, conditions for release of information contained in the record and which requires authorization in writing by the patient for release of appropriate information not otherwise authorized by law;

(2) A written policy which provides for the retention and storage of records for at least seven (7) years from the date of the last service to the patient and which provides for records retention and storage of such records in the event the agency discontinues operation;

(3) A policy and procedure manual governing the records system and procedures for all agency staff;

(4) Maintaining records on the agency's premises in lockable storage area(s).

(b) A record shall be developed for each patient which shall be filed in an accessible area within the agency and which shall include, but not be limited to:

(1) Identifying data (name, address, date of birth, sex, date of admission or readmission);

(2) Source of referral, including where applicable, name and type of institution from which discharged and date of discharge;

(3) Assessment of the patient and home;

(4) Plan of care and written instructions for the homemaker-home health aide;

(5) Name, address and phone number of patient's source of medical care;

(6) Pertinent past and current health history;

(7) Documentation of the registered nurse supervisor activities and, when appropriate, other professional supervisor(s) activities related to patient care;

(8) Documentation of coordination of services with the patient, family and others involved in the plan of care;

(9) Homemaker-home health aide notes which the registered nurse supervisor shall review, shall be incorporated in the patient's record no less often than every two (2) weeks;

(10) Discharge summary, if applicable.

(c) All notes and reports in the patient's record shall be typewritten or legibly written in ink, dated and signed by the recording person with his full name, or first initial, surname and title.

Notes

Conn. Agencies Regs. § 19-13-D88

Effective December 28, 1992