Utah Admin. Code R432-750-9 - Patient Records
(1)
(a) The hospice administrator shall develop
and implement record-keeping policies and procedures that address the use of
patient records by authorized staff, content, confidentiality, retention, and
storage.
(b) The licensee shall
ensure that records are organized in a uniform medical record format.
(c) The licensee shall maintain an
identification system to facilitate the location of each patient's current or
closed record.
(d) The licensee
shall maintain an accurate, current record for each patient receiving
service.
(e) Each licensee who has
a patient contact or provides a service shall ensure that a clinical note entry
of that contact or service is made in the patient's record.
(f) Any person making the entry shall date
and authenticate the entry with the person's signature and job title.
(g) The licensee shall document each service
provided and the outcome of each service in the individual patient
record.
(2)
(a) The licensee shall ensure that signed and
dated physician's orders are incorporated into the plan of care and renewed at
least every 90 days.
(b) A copy of
the order is acceptable as long as the original order is available on
request.
(3) The licensee
shall ensure that each patient record contains the following information:
(a) a signed, dated patient assessment that
includes the following:
(i) a description of
the patient's functional limitations;
(ii) a physical assessment noting chronic or
acute pain and other physical symptoms and their management;
(iii) a psychosocial assessment of the
patient and family;
(iv) a spiritual
assessment; and
(v) a written
summary report of hospice services provided that is additionally sent to the
patient's attending physician at least every 90 days;
(b) a written and signed informed consent to
receive hospice services;
(c) a
written plan of care;
(d) contact
information of:
(i) the name and address of
the nearest relative or responsible person;
(ii) the name and telephone number of the
person or family member who, in addition to hospice agency staff, provides care
in the place of residence; and
(iii) the name and telephone number of the
physician with primary responsibility for patient care;
(e) demographic information that includes the
patient's age, name, address, patient date of birth;
(f) diagnosis;
(g) medications and treatments as
applicable;
(h) pertinent medical
and surgical history if available; and
(i) orders by the attending physician for
hospice services.
(4)
(a) The person assigned to supervise or
coordinate care for a patient shall complete a discharge summary when services
to the patient are terminated.
(b)
The discharge summary shall include the reason for discharge and the name of
the facility or agency if the patient is referred or transferred.
(5) The licensee shall:
(a) ensure that written consent is required
for the release of patient information and photographing recorded
information;
(b) ensure that
written procedures govern the use and removal of records and conditions for the
release of patient information;
(c)
safeguard clinical record information against loss, destruction, and
unauthorized use; and
(d) send a
copy of the record to the new facility or agency when a patient is
transferred.
(6)
(a) The licensee shall provide an accessible
area for filing and safe storage of medical records.
(b) The licensee shall ensure that each
patient record is retained for at least seven years after the last date of
patient care.
(c) The licensee shall
transfer any patient records to a new owner upon a change of hospice agency
ownership.
Notes
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