KAR 28-51-110 — Clinical records and client records

What this rule requires your agency to do

• 1Each clinical and client record must be retained in retrievable form for at least five years after the patient's or client's last discharge, with provision for retention if the licensee discontinues operation (subsection (d)).(KAR 28-51-110 — Clinical records and client records)
• 2A clinical record or client record containing pertinent past and current findings must be maintained in accordance with accepted professional standards for each patient/client (subsection (a)).(KAR 28-51-110 — Clinical records and client records)
• 3Each client record must contain at least the plan of care, ordering practitioner's name, physician orders for drugs/diet/treatment/activity, signed dated admission notes, and documentation of supportive care services with check-in/out times and confirmation of delivery (subsection (c)(1)-(5)).(KAR 28-51-110 — Clinical records and client records)
• 4The agency must develop written policies and procedures on use and removal of documents and conditions for release of information (subsection (e)).(KAR 28-51-110 — Clinical records and client records)
• 5Each clinical record must contain at least the plan of care, ordering practitioner's name, drug/dietary/treatment/activity orders, signed dated admission and clinical notes written the day of service and incorporated at least weekly, and service-delivery documentation with date/time in and out (subsection (b)(1)-(5)).(KAR 28-51-110 — Clinical records and client records)
• 6Each clinical record must include HCBS documentation (if applicable), all progress notes, the date of each supervisory on-site visit required by K.A.R. 28-51-118, and the discharge summary report (subsection (b)(6)-(9)).(KAR 28-51-110 — Clinical records and client records)
• 7Each client record must include progress notes, the date of each supervisory on-site visit required by K.A.R. 28-51-117, and the discharge summary report (subsection (c)(6)-(8)).(KAR 28-51-110 — Clinical records and client records)
• 8The patient's, client's, or guardian's written consent is required for release of information not required by law (subsection (e)).(KAR 28-51-110 — Clinical records and client records)