10A NCAC 13K .0902       RECORD CONTENT, HANDLING AND RETENTION

(a)  The hospice agency shall develop and implement written policies governing the content, handling and retention of patient records.

(b)  The agency shall maintain a patient record for each patient.  Each page of the patient record shall have the patient's name.  All entries in the record shall reflect the actual date of entry.  Reference to any activity which occurred on a date prior to the date of entry shall be identified as a late or out of sequence entry.  A system for maintaining originals and copies shall be described in the agency policies and procedures.

(c)  The agency shall assure that originals of patient records are kept confidential and secure on the licensed premises unless in accordance with Rule .0209 of this Subchapter, or subpoenaed by a court of legal jurisdiction, or to conduct an evaluation as required in Rule .1001 of this Subchapter.

(d)  If a record is removed to conduct an evaluation, the record shall be returned to the agency premises within five working days.  The agency shall maintain a sign out log that includes to whom the record was released, patient's name and date removed.

(e)  A copy of the patient record for each patient must be readily available to the hospice staff providing services or managing the delivery of such services.

(f)  Patient records shall be retained for a period of not less than three years from the date of discharge of the patient, unless the patient is a minor in which case the record must be retained until five years after the patient's eighteenth birthday.  If a minor patient dies, as opposed to being discharged for other reasons, the minor's records must be retained at least five years after the minor's death.  When an agency ceases operation, the Department shall be notified in writing where the records will be stored for the required retention period.

 

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

Eff. November 1, 1984;

Amended Eff. February 1, 1996.