Section 325.21102. Patient clinical records.

(1) A clinical record shall be provided for each  patient  in the home. The clinical record shall be current and entries shall be dated and signed.

(2)   The clinical record shall include, at a minimum, all of the following:

(a)    The identification and summary sheet, which shall include all of the following patient information:

(i)   Name.

(ii)   Social security number.

(iii)   Veteran status and number.

(iv)   Marital status.

(v)   Age, sex, and home address.

(b)     Name,  address,  and   telephone  number  of  next  of  kin,  legal    guardian,  or designated representative.

(c)    Name, address, and telephone number of person or agency   responsible for patient's maintenance and care in the home.

(d)  Date of admission.

(e)    Clinical history and physical examination performed by the physician within 5 days before or on admission, including a report of chest x rays performed within 90 days of admission and a physician's treatment plan.

(f)   Admission diagnosis and amendments thereto during the course of  the patient's stay in the home.

(g)   Consent forms as required and appropriate.

(h)     Physician's orders for medications, diet, rehabilitative procedures, and other treatment or procedures to be provided to the patient.

(i)   Physician's progress  notes  written   at  the  time  of   each  visit describing  the patient's condition   and  other   pertinent   clinical observations.

(j)   Nurse's notes and observations by other personnel providing care.

(k)   Medication and treatment records.

(l)   Laboratory and x-ray reports.

(m)   ) Consultation reports.

(n)   Time and date of discharge,  final   diagnosis  and  place  to  which patient was discharged, condition on discharge, and name of person, if any, accompanying patient.

(3)       Copies of clinical history and physical examination report, discharge summary, transfer form, and other pertinent information arriving at the home with the patient upon transfer from another health facility shall be maintained in the facility.

(4)     Clinical  records   of  discharged  patients   shall  be  completed   within  30  days following discharge.

(5)   Clinical records shall be  under   the  supervision  of   a  full-time employee of the home.

(6)   Clinical records are retained for a minimum of 6 years from the date of discharge or, in the case of a minor, 3 years after the individual comes of age under state law, whichever is longer.

(7)   If a facility ceases to operate, the clinical records shall be transferred with the individual to another health care facility. It is the responsibility of the owner or corporate body to maintain clinical records of discharged patients for the length of retention as stated in subrule (6) of this rule.

(8)   If the department believes that patient  clinical  records  are  not being properly maintained or completed, the department may order a home to secure  from  a   registered

record   administrator   or   accredited   record technician on-site consultation of up to 4 hours per quarter until the problem is corrected.

History: 1981 AACS; 1983 AACS.