105 CMR, § 143.012 - Patient Records

(A) Each program shall keep in one centralized location on its premises records indicating all the services rendered to patients. Records shall contain sufficient information to justify the services and to document the results accurately.

(B) Each patient shall have a single integrated record. Each entry into each patient record shall be dated and authenticated by the staff member making the entry, indicating name and title. Each page of each patient's record shall have two unique forms of identification. The record with respect to each patient shall include the following:

(1) Patient's name, date of birth, sex, home address and telephone number; name, address and telephone number of referring physician and sponsor or responsible party, if any.

(2) Physician referral.

(3) Report of medical history and physical examination upon initiation of therapeutic exercise program component.

(4) Assessments, i.e. nursing assessment, psychosocial assessment. nutritional assessment and musculo/skeletal assessments.

(5) Report of any diagnostic tests (exercise tolerance test, Holter, echocardiogram. coronary catherization, blood tests. etc.

(6) Discharge summary from most recent hospitalization.

(7) Report of most recent electrocardiogram.

(8) Informed consent for treatment.

(9) Date of each patient visit with program staff.

(10) Progress notes which include documentation of progress toward goals of the treatment plan.

(11) Documentation that progress reports were communicated to the referring physician on a regular basis.

(12) Orders for any medication, test, or treatment.

(13) Records of any administration of medications, treatment, or therapy.

(14) Maximal symptom limited exercise tolerance test prior to Phase III.

(15) Discharge evaluation.

(C) Each program shall maintain patient records under lock or code and use them in a manner to protect the confidentiality of the information contained therein. Printed copies of electronically stored records shall be disposed of in a manner which assures the confidentiality of patient information.

Notes

105 CMR, § 143.012