Section 131.33. Clinical record.

 

(1)   General. A hospice shall establish a single and complete clinical record for every patient. Clinical record information shall remain confidential except as required by law or a third-party payment contract.

(2)   Documentation and accessibility. The clinical record shall be completely accurate and up-to-date, readily accessible to all individuals providing services to the patient or the patient's family, or both, and shall be systematically organized to facilitate prompt retrieval of information.

(3)   Content. A patient's clinical record shall contain all of the following:

(a) The initial, integrated and updated plans of care prepared under s. DHS 131.21 .

(b) The initial, comprehensive and updated comprehensive assessments.

(c) Complete documentation of all services provided to the patient or the patient's family or both, including:

1. Assessments.

2. Interventions.

3. Instructions given to the patient or family, or both.

4. Coordination of activities.

(d) Signed copies of the notice of patient rights under s. DHS 131.19 (1) (a) and service authorization statement under s. DHS 131.17 (4) (b) .

(e) A current medications list.

(f) Responses to medications, symptom management, treatments, and services.

(g) Outcome measure data elements, as described in s. DHS 131.20 (5) .

(h) Physician certification and recertification of terminal illness.

(i) A statement of whether or not the patient, if an adult, has prepared an advance directive; and a copy of the advance directive, if prepared.

(j) Physician orders.

(k) Patient and family identification information.

(L) Referral information, medical history and pertinent hospital discharge summaries.

(m) Transfer and discharge summaries.

(4)   Authentication.

(a) Entries. All entries shall be legible, permanently recorded, dated and authenticated by the person making the entry, and shall include that person's name and title.

(b) Written record. A written record shall be made for every service provided on the date the service is provided. This written record shall be incorporated into the clinical record no later than 7 calendar days after the date of service.

(c) Medical symbols. Medical symbols and abbreviations may be used in the clinical records if approved by a written program policy which defines the symbols and abbreviations and controls their use.

(d) Protection of information. Written record policies shall ensure that all record information is safeguarded against loss, destruction and unauthorized usage.

(e) Retention and destruction.

1. An original clinical record and legible copy or copies of court orders or other documents, if any, authorizing another person to speak or act on behalf of the patient shall be retained for a period of at least 5 years following a patient's discharge or death when there is no requirement in state law. All other records required by this chapter shall be retained for a period of at least 2 years.

2. A hospice shall arrange for the storage and safekeeping of records for the periods and under the conditions required by this paragraph in the event the hospice closes.

3. If the ownership of a hospice changes, the clinical records and indexes shall remain with the hospice.

History: CR 10-034 : cr. Register September 2010 No. 657 , eff. 10-1-10.