Clinical Records - In accordance with accepted principles of practice the hospice

Clinical Records - In accordance with accepted principles of practice the hospice shall establish and maintain a clinical record for every individual receiving care and services. The record shall be complete, promptly and accurately documented, readily accessible and systematically organized to facilitate retrieval. The clinical record shall contain all pertinent past and current medical, nursing, social and other therapeutic information, including the current POC under which services are being delivered. 1. All clinical records shall be safeguarded against loss, destruction and unauthorized use and shall be maintained at the hospice site issued the license. (S.O.M. 208.1) 2. Hospice records must be maintained in a distinct location and not mingled with records of other types of health care related agencies. 3. Clinical records shall be kept in a safe and confidential area which provides convenient access to clinicians. 4. The agency shall have policies addressing who is permitted access to the clinical records. No unauthorized person shall be permitted access to the clinical records. 5. Records shall be maintained from the patient’s effective date of discharge, as per State law. 6. When applicable, the agency will obtain a signed “Release of Information” from the patient and /or the patient’s family. A copy will be retained in the record. 7. The clinical record shall contain a comprehensive compilation of information including, but not limited to, the following: a. Initial and subsequent Plans of Care and initial assessment; b. Certifications of terminal illness; c. Written physician’s orders for admission and changes to the POC; d. Current clinical notes (at least the past sixty (60) days; e. Plan of Care; f. Signed consent, authorization and election forms; g. Pertinent medical history; and h. Identifying data, including name, address, date of birth, sex, agency case number and next of kin. 8. Entries for all provided services must be documented in the clinical record and must be signed by the staff providing the service. 9. Complete documentation of all services and event (including evaluations, treatments, progress notes, etc.) are recorded whether furnished directly by hospice staff or by arrangement.