Utah Admin. Code R432-700-17 - Client Records

(1) The licensee shall develop and implement record-keeping policies and procedures that address use of client records by authorized staff, content, confidentiality, retention, and storage.

(2) Records shall be maintained in an organized format.

(3) The agency shall maintain a client record identification system to facilitate locating each client's current or closed record.

(4) An accurate, up-to-date record shall be maintained by the licensee, for each client receiving service through the agency.

(a) Each person who has client contact or provides a service in the client's place of residence shall enter a clinical note of that contact or service in the client's record.

(b) The licensee shall ensure that client record entries are dated and authenticated with the signature, or identifiable initials of the person making the entry.

(c) The licensee shall document each service provided by the licensee and outcomes of these services in the individual client record.

(5) The licensee shall ensure that each client record contains the following information:

(a) identification data including client name, address, age, and date of birth;

(b) name and address of nearest relative or responsible individual;

(c) name and telephone number of the primary care provider with responsibility for client care;

(d) name and telephone number of any person or family member who provides care in the place of residence;

(e) a written plan of care;

(f) a signed and dated client assessment that identifies pertinent information required to carry out the plan of care;

(g) reasons for referral to the home health agency;

(h) statement of the suitability of the client's place of residence for the provision of health care services;

(i) documentation of telephone consultation or case conferences with other individuals providing services;

(j) signed and dated clinical notes for each client contact or home visit including services provided; and

(k) a written termination of services summary that describes:

(i) the care or services provided;

(ii) the course of care and services;

(iii) the reason for discharge;

(iv) the status of the client at time of discharge; and

(v) the name of the agency or facility if the client was referred or transferred.

(6) For a client who receives skilled services, the licensee shall additionally include the following items in the client record:

(a) diagnosis;

(b) pertinent medical and surgical history;

(c) a list of medications and treatments;

(d) allergies or reactions to drugs or other substances;

(e) any clinical summaries or other documents obtained when necessary for promoting continuity of care, especially when a client receives care elsewhere, to include:

(i) a hospital;

(ii) an ambulatory surgical center;

(iii) a nursing home;

(iv) a primary care providers or consultant's office; or

(v) other home health agency; and

(f) clinical notes to include a description of the client condition and significant changes such as:

(i) objective signs of illness, disorders, and body malfunction;

(ii) subjective information from the client and family;

(iii) general physical condition;

(iv) general emotional condition;

(v) positive or negative physical and emotional responses to treatments and services;

(vi) general behavior; and

(vii) general appearance.

Notes

Utah Admin. Code R432-700-17

Amended by Utah State Bulletin Number 2022-05, effective 2/14/2022 Amended by Utah State Bulletin Number 2023-14, effective 7/6/2023