SECTION 700
PATIENT RECORDS

701 General
The hospice shall maintain and store a record for each hospice patient in a manner that ensures confidentiality, security, and integrity of the information.

702 Content (II)
A. The hospice shall initiate and maintain an organized record for each patient. The record shall contain sufficient documented information to identify the patient and verify appropriate care rendered. All entries shall be written legibly in ink or typed, signed, and dated.

B. Specific entries/documentation shall include at a minimum:

1. Consultations by physicians or other authorized healthcare providers;

2. Orders for all medication, care, treatment, services, and procedures from physicians or other authorized healthcare providers shall be completed prior to, or at the time of admission, and updated when revised. Verbal orders received shall include the date of receipt of the order, description of the order, and identification of the individual receiving the order;

3. Care/treatment/services provided;

4. Medications administered and procedures followed if an error is made, to include adverse reactions;

5. Notes of observation;

6. Time and circumstances of death or of discharge/transfer, including condition at discharge/transfer.

703 Assessment
An individualized assessment of physical, emotional, and spiritual needs shall be conducted at the time of admission for each patient. It is acceptable to utilize the same assessment of a patient moving from a hospice to a hospice facility or vice versa if both are owned by the same licensee.

704 Plan of Care (II)
A plan of care (POC) (See 101.MM) shall be developed by the interdisciplinary team within 48 hours of admission, approved by a physician, and updated as needed, and shall include the care, treatment, and services relative to the needs of the patient and maintained in the patient record. It is acceptable to utilize the same POC of a patient moving from a hospice to a hospice facility or vice versa that is owned by the same licensee.

705 Record Maintenance
A. The licensee shall provide accommodations, space, supplies, and equipment adequate for the function, protection, and storage of patient records.

B. When a patient is transferred from a hospice to another hospice or facility, copies of appropriate supporting documentation to include at a minimum, a copy of the POC and medication record shall be forwarded to the receiving hospice or facility at the time of transfer. (II)

C. The patient record is confidential and may be made available only to authorized individuals. Active patient records, with the exception of records utilized by providers during home visits, shall be available at the hospice at all times and shall be accessible by the staff member in charge and by other authorized individuals such as representatives of the Department. (II)

D. Records generated by organizations/individuals with whom the hospice contracts for care, treatment, or services shall be maintained by the hospice that has admitted the patient.

E. The hospice shall determine the medium in which information is stored.

F. Agencies employing electronic signatures or computergenerated signature codes shall insure authentication and security.

G. Upon discharge of a patient, the patient record shall be completed and filed in an inactive/closed file within a time period as determined by the hospice, but no later than 30 days after discharge. Closed patient records shall be stored by the licensee and retained for six years following the discharge of the patient. Such records shall be made available to the Department upon request.

H. Upon discharge of the hospice patient’s family from bereavement services, the bereavement information shall be filed in an inactive/closed file within a timeperiod as determined by the hospice. Closed bereavement information shall be stored by the licensee and retained for six years following the completion of services.

I. Prior to the closing of a hospice for any reason, the licensee shall arrange for preservation of records to insure compliance with these regulations. The licensee shall notify the Department, in writing, describing these arrangements within 10 days of closure.

J. Patient records may be destroyed after six years provided that records of minor patients are retained until after the expiration of the period of election following achievement of majority as prescribed by statute.

K. Records of patients are the property of the hospice and shall not be removed from the designated patient record storage area, to include onsite, offsite, or contracted storage, without court order, except when care is delivered in the home or the hospice facility.

EXCEPTION: When a patient is transferred from one hospice to another hospice within the same provider network (same licensee), the original record may follow the patient; the sending hospice shall maintain documentation of the patient’s transfer/discharge date and identification information. In the event of change of ownership, all active patient records or copies of active patient records shall be transferred to the new owner(s).