42 CFR 484.110 — Condition of Participation: Clinical Records

What this rule requires your agency to do

• 1The HHA must make a patient's clinical record available to the patient, free of charge, upon request at the next home visit or within 4 business days, whichever comes first (subd. e).(42 CFR 484.110 — Condition of Participation: Clinical Records)
• 2The HHA's policies must provide for retention of clinical records even if it discontinues operation, and upon discontinuing operation the HHA must inform the state agency where clinical records will be maintained (subd. c(2)).(42 CFR 484.110 — Condition of Participation: Clinical Records)
• 3The HHA must safeguard the clinical record and its contents against loss or unauthorized use and comply with the protected health information rules at 45 CFR parts 160 and 164 (subd. d).(42 CFR 484.110 — Condition of Participation: Clinical Records)
• 4The HHA must retain clinical records for at least 5 years after the patient's discharge, unless state law requires a longer period (subd. c(1)).(42 CFR 484.110 — Condition of Participation: Clinical Records)
• 5The HHA must send a completed discharge summary to the post-discharge care provider within 5 business days of discharge, a completed transfer summary within 2 business days of a planned transfer, or a completed transfer summary within 2 business days of becoming aware of an unplanned transfer (subd. a(6)).(42 CFR 484.110 — Condition of Participation: Clinical Records)
• 6All clinical record entries must be legible, clear, complete, and appropriately authenticated, dated, and timed, with authentication including a signature and title (or a secured computer entry by unique identifier) of a primary author who has reviewed and approved the entry (subd. b).(42 CFR 484.110 — Condition of Participation: Clinical Records)
• 7The HHA must maintain an accurate clinical record containing past and current information for every patient accepted and receiving home health services, adhering to current clinical record documentation standards and available to the ordering physician/allowed practitioner and appropriate HHA staff (introductory paragraph).(42 CFR 484.110 — Condition of Participation: Clinical Records)
• 8The clinical record must include the patient's current comprehensive assessment (including all assessments from the most recent admission), clinical notes, plans of care, physician/allowed practitioner orders, all interventions and responses, plan-of-care goals and progress, and contact information for the patient, representative, primary caregivers, and post-discharge care provider (subd. a(1)–(5)).(42 CFR 484.110 — Condition of Participation: Clinical Records)