Title 7 . Health and Social Services

Chapter 12 . Assistance for Community Health Facilities

Section 561. Clinical records

7 AAC 12.561. Clinical records

(a) A home health agency shall maintain a clinical record for each patient. The clinical record must be legible and maintained in accordance with accepted professional or occupational standards. The clinical record must be readily available upon the request of the

(1) attending physician;

(2) the department;

(3) the patient;

(4) the patient's representative; or

(5) if authorized by the patient, another health care provider.

(b) A clinical record must include the following items:

(1) appropriate identifying information;

(2) assessments by appropriate personnel;

(3) the plans of care;

(4) name of the attending physician;

(5) signed and dated clinical progress notes;

(6) copies of summary reports sent to the attending physician;

(7) a signed patient release or consent forms, if indicated;

(8) documentation of informed consent regarding the initiation of care and treatment, and changes in the plan of care;

(9) evidence the patient received the patients' rights under 7 AAC 12.534 and advance directive information under 7 AAC 12.537;

(10) copies of transfer information sent with the patient; and

(11) a discharge summary.

(c) Clinical progress notes must be written or dictated on the day that care or service is rendered. The clinical progress notes must be incorporated into the patient's clinical record within seven days. Summaries of the care or service reported must be submitted to the attending physician at least every 62 days.

(d) A home health agency shall have written policies and procedures to provide that clinical records are

(1) legibly written in ink or typed, suitable for photocopying;

(2) readily available to authorized personnel during operating hours of the agency;

(3) protected from damage;

(4) if computerized, have a security mechanism in place to ensure confidentiality;

(5) retained for five years after the date of discharge, or, in the case of a minor, three years after the patient turns 21 years of age; agency policy and procedures must provide for record retention even if the home health agency discontinues operation;

(6) disposed of using a method that will prevent retrieval and subsequent use of information; and

(7) transferred with the patient if the patient transfers to another agency or health facility; the transferred record may be a copy or an abstract and a summary report.

History: Eff. 9/6/96, Register 139

Authority: AS 18.05.040