Ga. Comp. R. & Regs. R. 111-8-31-.09 - Standards for Patient Care
Patients shall be accepted for treatment on the basis of a reasonable expectation that the patient's medical, nursing, and social needs can be met adequately by the agency in the patient's place of residence. Patients shall not be denied services because of their age, sex, race, religion, or national origin. Care shall follow a written plan of treatment established and periodically reviewed by a physician, and shall continue under the supervision of a physician.
(a)
Plan of Treatment. An individual plan of treatment shall be developed for each
patient in consultation with agency staff, and shall cover all pertinent
diagnosis, including mental status, types of services and equipment required,
frequency of visits, prognosis, rehabilitation potential, functional
limitations, activities permitted, nutritional requirements, medications and
treatments, safety measures to protect against injury, instructions for timely
discharge or referral, and other appropriate items. If a physician refers a
patient under a plan of treatment which cannot be completed until after an
evaluation visit, the physician shall be consulted to approve additions or
modifications to the original plan. Orders for therapy services shall specify
the procedures and modalities to be used, and the amount, frequency, and
duration.
(b) Periodic Review of
Plan of Treatment. The total plan of treatment shall be reviewed by the
attending physician and home health agency personnel as often as the severity
of the patient's condition requires, but at least once every sixty (60) days.
Date of the review and approval of the plan shall be documented by the
physician's signature. Agency professional staff shall promptly alert the
physician to any changes that suggest a need to alter the plan of
treatment.
(c) Conformance with
Physician's Orders. Drugs and treatment shall be administered by agency staff
only as ordered by the physician. The nurse or therapist shall immediately
record and sign oral orders and forward the written order within five (5)
business days to the physician for countersignature. Documentation of the
physician's countersignature must appear in the patient's medical record within
thirty (30) days of the verbal order. Professional agency staff shall check all
medicines a patient may be taking to identify possible ineffective drug therapy
or adverse reactions, significant side effects, drug allergies, and
contraindicated medication, and shall promptly report any problems to the
physician.
(d) Clinical Records.
1. A clinical record shall be established and
maintained on each patient in accordance with accepted professional standards
and shall contain:
(i) pertinent past and
current findings;
(ii) plan of
treatment;
(iii) appropriate
identifying information;
(iv) name
of physician;
(v) drug, dietary,
treatment and activity orders;
(vi)
signed and dated clinical and progress notes (clinical notes are written the
day service is rendered by the providing member of the health team and
incorporated no less often than weekly);
(vii) copies of case conferences;
(viii) copies of summary reports sent to the
physician; and
(ix) a discharge
summary.
2. If a patient
transfers to another home health agency or a health facility, a copy of the
record or abstract shall be furnished to accompany the patient.
3. Sufficient space and equipment for record
processing, storage and retrieval shall be provided.
4. Policies and procedures shall be written
and implemented to assure organization and continuous maintenance of the
clinical records system.
(e) Retention of Records. Clinical records
shall be retained for a period of six years after the last patient encounter
for adults, and for six years after a minor reaches the age of majority. These
records may be retained as originals, microfilms, or other usable forms and
shall afford a basis for complete audit of professional information. If the
home health agency dissolves or changes ownership, a plan for record retention
shall be developed and placed into effect. The Department shall be advised of
the disposition and/or location of said records.
(f) Protection of Records. Clinical record
information shall be safeguarded against loss or unauthorized use. Written
procedures shall govern the use and removal of records and conditions for
release of information. A patient's written consent is required for release of
information not authorized by law.
Notes
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No prior version found.