Clinical Records

Section 280 Section 280.2060  Clinical Records Each hospice must establish and maintain a clinical record for every individual receiving services. a) The hospice program shall keep accurate, current and confidential records on all hospice patients and their families in accordance with the standards for certification under the Medicare program set forth in the Conditions of Participation in 42 CFR 418, except standards or conditions in connection with Medicare or Medicaid election forms do not apply to patients receiving hospice care at no charge. (Section 8(i) of the Act) b)         A standardized format shall be used for documenting: 1)         Hospice care team services; 2)         Home care services; and 3)         Inpatient services. c)         Record entries shall be made by hospice staff members or individuals providing services under contract. d)         All entries into the medical record shall be authenticated by the individual who made or authorized the entry.  "Authentication", for purposes of this Section, means identification of the author of a medical record entry by the author, and confirmation that the contents are what the author intended. e)         The medical record may include entries that are transmitted by facsimile machine, provided that the faxed copies will be maintained on non-thermal paper and that the faxed copies will be dated and authenticated in accordance with hospice policy. f)         Written signatures or initials and electronic signatures or computer-generated signature codes are acceptable as authentication.  All signatures or initials, whether written, electronic, or computer-generated, shall include the initials of the signer's credentials. g)         In order for a hospice to employ electronic signatures or computer-generated signature codes for authentication purposes, the hospice shall adopt a policy that permits authentication by electronic or computer-generated signature.  The policy shall identify those categories of the staff or other personnel within the hospice who are authorized to authenticate patient records using electronic or computer-generated signatures. h)         At a minimum, the policy shall include adequate safeguards to ensure confidentially, including, but not limited to, the following: 1)         Each user shall be assigned a unique identifier that is generated through a confidential access code. 2)         The hospice shall certify in writing that each identifier is kept strictly confidential.  This certification shall include a commitment to terminate a user's use of a particular identifier if it is found that the identifier has been misused.  "Misused" shall mean that the user has allowed another person or persons to use his or her personally assigned identifier, or that the identifier has otherwise been inappropriately used. 3)         The user shall certify in writing that he or she is the only person with user access to the identifier and the only person authorized to use the signature code. 4)         The hospice shall monitor the use of identifiers periodically and take corrective action as needed.  The process by which the hospice will conduct the monitoring shall be described in the policy. i)          Progress notes shall be signed and dated by the person providing the services. j)          The record shall include a conclusion or evaluation at the termination of hospice care, including a referral of the patient, and the hospice patient's family to another resource, if applicable. k)         The record for each patient and the hospice patient's family receiving hospice home care services shall include: 1)         The names of persons who are assuming responsibility for the care of the patient at home; and 2)         The suitability or adaptability of the residence for the provision of required services. l)          The documentation must reflect the physical condition of the patient, the psychosocial status of the patient and the hospice patient's family, and the care provided from admission through discharge. m)        Each hospice must have a written policy to identify how it will safeguard clinical records against loss, destruction and unauthorized use. n)         A patient's clinical records shall be maintained by the hospice for at least five years beyond the last date of service.