Medical records

1. The hospice program must keep accurate, current, and confidential records of all hospice patients and their families. The hospice program must safeguard the medical record against loss, destruction, and unauthorized use. Overall responsibility for medical records must be assigned to an employee of the hospice program. 2. The medical record must be complete, and documented promptly, accurately, and legibly. 3. Each medical record must contain sufficient information on all services provided, whether furnished directly or under arrangement by the hospice program, and entries must be signed with the legally acceptable signature by the person making the entry. Each patient and family medical record must contain, but is not limited to, the following: a. Complete identification of each patient, including information on the patient's next of kin and responsible person or agency. b. The initial and subsequent assessments by each discipline involved with the patient and family. c. A medical history obtained prior to the development of a hospice care plan. d. A current hospice care team plan. e. Complete documentation of all home visits and services rendered if the service is provided directly. f. If home care is not provided directly, provision must be made for the hospice program to obtain, as a minimum, a summary of services provided that reflect pertinent information relevant to the patient's and family's care. g. Consent and authorization forms. h. Patient diagnosis and prognosis certified by the attending physician. i. Legible therapeutic orders authenticated by the attending physician. Action must be initiated by the hospice program to obtain the physician's signature for verbal orders within forty-eight hours. j. At the time of discharge or transfer, the hospice must provide those responsible for the patient's care with an appropriate summary of information, including the hospice service plan, about the patient to ensure the optimal continuity of care. k. Bereavement care plan and progress notes including bereavement assessment and followup. 4. Pertinent information regarding patient needs must accompany the patient upon discharge from the inpatient setting, and must be included as part of the hospice medical record. 5. The medical record of a discharged patient must be completed within thirty days after discharge. 6. Records must be maintained by the agency for a period of not less than ten years following the date of discharge or death. In the case of a minor, the records must be maintained for a period of twelve years following the date of discharge or death.