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10A NCAC 13J .1402 - Content of Record (Service Records for Home Care Agency Clients)

North CarolinaregulationNorth Carolina Medical Care Commission / DHHS Division of Health Service Regulation (Acute and Home Care Licensure and Certification Section)

What this rule requires your agency to do

  • 1For clients receiving services that require a physician's order, the agency must additionally document client diagnoses and physician orders for medications and treatments. (10A NCAC 13J .1402)(10A NCAC 13J .1402 - Content of Record (Service Records for Home Care Agency Clients))
  • 2The agency must maintain a client service record containing, at a minimum, the information specified in the rule for each client served. (10A NCAC 13J .1402)(10A NCAC 13J .1402 - Content of Record (Service Records for Home Care Agency Clients))
  • 3The agency must maintain a record of all services provided, both directly and by contract, and a discharge summary stating the reason for discharge. (10A NCAC 13J .1402)(10A NCAC 13J .1402 - Content of Record (Service Records for Home Care Agency Clients))
  • 4The agency must document initial assessments of the client's functional status in the areas of social, mental, physical health, environmental, economic, ADLs, and IADLs, along with problems identified, goals established, and proposed interventions. (10A NCAC 13J .1402)(10A NCAC 13J .1402 - Content of Record (Service Records for Home Care Agency Clients))
  • 5For clients receiving services that do not require a physician's order, the agency must document admission/identification data including name, address, telephone number, date of birth, sex, marital status, social security number, and names of next of kin or legal guardian. (10A NCAC 13J .1402)(10A NCAC 13J .1402 - Content of Record (Service Records for Home Care Agency Clients))
  • 6The agency must include in the service record a copy of the signed client's rights form or documentation of its delivery. (10A NCAC 13J .1402)(10A NCAC 13J .1402 - Content of Record (Service Records for Home Care Agency Clients))
  • 7The agency must document the source of referral and an assessment of the client's home environment. (10A NCAC 13J .1402)(10A NCAC 13J .1402 - Content of Record (Service Records for Home Care Agency Clients))

Applies to: home care

North Carolina's home care agency licensure rules (10A NCAC 13J, Section .1400 - Service Records) require each licensed home care agency to maintain a service record for every client. Rule .1402 (Content of Record) specifies the minimum contents of the service record, distinguishing between clients whose services do not require a physician's order and those whose services do. Required contents include client identification/admission data, a copy of the signed client's rights form or documentation of its delivery, source of referral, an assessment of the home environment, initial functional assessments, identified problems/goals/interventions, a record of all services provided (directly and by contract), and a discharge summary; records for physician-ordered services must also include diagnoses and physician orders for medications and treatments.

Regulatory information, not legal advice — always confirm against the cited official source. Verification reduces error; it does not certify compliance.