Section 7.12.339. Clinical and administrative records.

	(a)  A hospice agency shall establish and maintain a clinical record for each client receiving care and services. The record must provide for identification, security, confidentiality, control, retrieval, and preservation of client care data and information. Each clinical record must be a comprehensive compilation of information. The agency shall ensure that entries are  
		(1) made for all services provided, whether furnished directly by or indirectly through the agency; and  
		(2) made and signed by the staff providing the services.  
	(b)  Each client's clinical record must contain  
		(1) appropriate identifying information;  
		(2) assessments by appropriate personnel;  
		(3) the client's plan of care;  
		(4) the name of the attending physician or advanced nurse practitioner;  
		(5) signed and dated progress notes;  
		(6) copies of summary reports sent to the attending physician or advanced nurse practitioner;  
		(7) a signed client release or consent form;  
		(8) documentation of informed consent regarding the initiation of care and treatment and changes in the plan of care;  
		(9) evidence that the client was informed regarding advance health care directives and client rights as described in 7 AAC 12.320;  
		(10) copies of any transfer information sent with the client; and  
		(11) a discharge summary, if appropriate.  
	(c)  Clinical progress notes must be written or dictated on the day that care or service is provided. The clinical progress notes must be incorporated into the client's clinical record within seven days.  
	(d)  A hospice agency shall have written policies and procedures to ensure that clinical records are  
		(1) legibly written in ink or typed, and suitable for photocopying;  
		(2) readily available to authorized personnel during operating hours of the agency;  
		(3) protected from damage;  
		(4) if electronic, protected by security software designed to ensure confidentiality;  
		(5) retained for at least five years after the date of discharge, or in the case of a minor, three years after the client turns 21 years of age; agency policies and procedures must provide for record retention even if the agency discontinues operation;  
		(6) disposed of using a method that will prevent retrieval and subsequent use of information; and  
		(7) transferred with the client if the client transfers to another agency or health facility; the transferred record may be  
			(A) a copy; or  
			(B) an abstract and a summary report.  
	(e)  In addition to maintaining clinical records as described in this section, a hospice agency shall maintain administrative records that, at a minimum, include  
		(1) minutes of governing body meetings;  
		(2) all receipts and expenditures; and  
		(3) training provided to paid staff and volunteers.  

Authorities

47.32.010;47.32.030

Notes

Reference

7 AAC 12.310

Authority

AS 47.32.010 AS 47.32.030

History

Eff. 5/24/2007, Register 182