SECTION .0900 ‑ MEDICAL RECORDS

 

10A NCAC 13K .0901       CONTENT OF MEDICAL RECORD

(a)  The hospice shall develop and implement policies and procedures to ensure that a medical record is maintained for each patient and is made available for licensure inspection.  If the patient or responsible party wishes to deny the Department access to the medical record, that person shall sign a statement denying access.  This statement shall be kept at the front of the record.  If the patient is not able to approve or disapprove the release of such information for inspection, the patient's legal guardian shall make the decision and so indicate in writing.

(b)  The record shall contain past and current medical and social data and include the following information:

(1)           identification data (name, address, telephone, date of birth, sex, marital status);

(2)           name of next of kin or legal guardian;

(3)           names of other family members;

(4)           religious preference and church affiliation and spiritual caregiver if appropriate;

(5)           diagnosis, as determined by attending physician;

(6)           authorization from attending physician for hospice care;

(7)           source of referral;

(8)           initial assessments, including physical, social, spiritual, environmental, and bereavement;

(9)           consent for care form;

(10)         physician's orders for drugs, treatments and other special care, diet, activity and other specific therapy services;

(11)         care plan;

(12)         clinical notes containing a record of all professional services provided directly or by contract with entries signed by the individual providing the services;

(13)         nurse aide and hospice caregiver notes describing activities performed and pertinent observations;

(14)         a copy of the signed patient's rights form or documentation of its delivery;

(15)         patient family volunteer notes, as applicable, indicating type of contact, activities performed and time spent;

(16)         discharge summary to include services provided, or reason for discharge if services are terminated prior to the death of the patient; and

(17)         bereavement counseling notes.

 

History Note:        Authority G.S. 131E‑202;

Eff. November 1, 1984;

Amended Eff. April 1, 1996; February 1, 1995; November 1, 1989.