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10-144 C.M.R. ch. 119, § 7.F - Patient/Client Records (Home Health Care Services)

MaineregulationMaine Department of Health and Human Services, Division of Licensing and Certification

What this rule requires your agency to do

  • 1The provider must retain records at the agency's main business or subunit office(s) for a minimum of five years, or longer if required by state and federal law, beyond the last date of service provided. (10-144 C.M.R. ch. 119, § 7.F.2)(10-144 C.M.R. ch. 119, § 7.F.2)
  • 2The provider must maintain a medication list with all medications listed with start and stop dates, side effects, and contraindications. (10-144 C.M.R. ch. 119, § 7.F.1.d)(10-144 C.M.R. ch. 119, § 7.F.1.d)
  • 3The provider must record signed and dated clinical notes for each contact, written on the day of service. (10-144 C.M.R. ch. 119, § 7.F.1.h)(10-144 C.M.R. ch. 119, § 7.F.1.h)
  • 4The provider must document appropriate identifying information about the patient/client, household members and caretakers, medical history and current findings, and psychosocial history in the clinical record. (10-144 C.M.R. ch. 119, § 7.F.1.a)(10-144 C.M.R. ch. 119, § 7.F.1.a)
  • 5The provider must initiate and maintain an identifiable clinical record for each patient/client in accordance with accepted professional standards. (10-144 C.M.R. ch. 119, § 7.F.1)(10-144 C.M.R. ch. 119, § 7.F.1)
  • 6The provider must document evidence that the patient/client is under the supervision of a physician who is available for emergencies. (10-144 C.M.R. ch. 119, § 7.F.1.b)(10-144 C.M.R. ch. 119, § 7.F.1.b)
  • 7The provider must include in the record a care plan developed by a registered professional nurse or, where appropriate, the physical therapist, occupational therapist, speech pathologist, dietitian, or medical social worker. (10-144 C.M.R. ch. 119, § 7.F.1.c)(10-144 C.M.R. ch. 119, § 7.F.1.c)

Applies to: home health / home care

Maine's home health care services licensing rule (Chapter 119, Section 7.F) requires each provider to initiate and maintain an identifiable clinical record for every patient/client, specifies required record content (identifying/medical/psychosocial data, physician supervision evidence, a care plan, a medication list, and signed dated clinical notes for each contact), and sets a minimum five-year retention period at the agency office.

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