Content - Each clinical record shall be comprehensive compilation of

Content - Each clinical record shall be comprehensive compilation of information. Entries shall be made for all services provided and shall be signed and dated within 7 days by the individual providing the services. The record shall include all services whether furnished directly or under arrangements made by the hospice. Each patient’s record shall contain: 1. Identification data; 2. The initial and subsequent assessments; 3. The plan of care; 4. Consent and authorization forms; 5. Pertinent medical and psychosocial history; 6. Complete documentation of all services and events (including evaluations, treatments, progress notes, etc.)