The center must adopt, implement, enforce and maintain a clinical record system to assure that the care and services provided to each client is completely and accurately documented, and systematically organized to facilitate the compilation and retrieval of information. At the time of an on-site survey, all clinical records shall be readily retrievable for review within two hours of the request. (1) For each client, a center may keep a single file or separate files for each stage of service provided to the client. (2) The center shall have written procedures which are adopted, implemented, and enforced regarding the removal of records and the release of information. A center shall not release any portion of a client record to anyone other than the client except as allowed by law. (3) All information regarding the client's care and services shall be centralized in the client's record and be protected against loss or damage. (4) The center shall establish an area for client record storage at the center's place of business. The client record shall be stored at the place of business from which services are actually provided. (5) The center shall ensure that each client's record is treated with confidentiality, safeguarded against loss and unofficial use, and is maintained according to professional standards of practice. (6) The clinical record shall be an original, a microfilmed copy, an optical disc imaging system, or a certified copy. An original record includes manually signed paper records or electronically signed computer records. Computerized records shall meet all requirements of paper records including protection from unofficial use and retention for the period specified in paragraph (10) of this subsection. Systems shall assure that entries regarding the delivery of care or services may not be altered without evidence and explanation of such alteration. (7) Each entry to the client record shall be accurate, signed, and dated with the date of entry by the individual making the entry. Correction fluid or tape shall not be used in the record. Corrections shall be made by striking through the error with a single line and shall include the date the correction was made and the initials of the person making the correction. (8) Inactive client records may be preserved and stored on microfilm, optical disc or other electronic means. Security shall be maintained and records must be readily retrievable by the center within two hours of a request for a record(s) by the department. (9) The clinical record must contain the following: (A) client identifying information; (B) name of the client's birth attendant(s) and the name of all other clinical care providers; (C) initial risk assessment; (D) a disclosure statement and informed consent that is signed by a client that explains the benefits, limitations, and risks of the services available to them at the center, and that describes the collaborative arrangements that the center has with physicians and with referral hospitals; (E) the informed choice agreement required to be given a client by a licensed midwife, if applicable; (F) record of antepartum (prenatal) care; (G) history and physical examination of the clients; (H) laboratory procedures; (I) progress notes shall be written, signed and dated by the person rendering the service on the day service is rendered and incorporated into the client record on a timely basis; (J) medication list and medication administration record, if applicable; (K) intrapartum care; (L) newborn care; (M) postpartum care; (N) allergies and medication reactions; (O) documentation for consultation; (P) refusal of the client to comply with advice or treatment; (Q) discharge summary; (R) documentation of client transfers or referrals, if applicable; and (S) documentation that: (i) a birth certificate was filed; or (ii) if applicable, a death certificate was filed. (10) A center shall retain original client records for a minimum of five years after the discharge of the client. The center may not destroy client records that relate to any matter that is involved in litigation if the center knows the litigation has not been finally resolved. (11) If a center closes, there shall be an arrangement for the preservation of inactive records to ensure compliance with this section. The center shall send the department written notification of the reason for closure, the location of the client records and the name and address of the client record custodian. If a center closes with an active client roster, a copy of the active client record shall be transferred with the client to the receiving center or other health care facility in order to assure continuity of care and services to the client. |
