LAC 48:I.9129 — Clinical Records (Minimum Standards for Home Health Agencies)

What this rule requires your agency to do

• 1The agency shall maintain a clinical record (paper or electronic) for every patient accepted for home health service, accessible to authorized staff, with information that is accurate and immediately available to the patient's authorized healthcare provider (§I-9129.A.1).(LAC 48:I.9129 — Clinical Records (Minimum Standards for Home Health Agencies))
• 2An active clinical record shall contain the initial assessment, current signed/dated plan of care, current comprehensive assessment, clinical notes for at least the past 60 days, identifying data, medication list, current medical orders, diagnoses, services rendered, functional status, prognosis, and discharge summary (§I-9129.C).(LAC 48:I.9129 — Clinical Records (Minimum Standards for Home Health Agencies))
• 3The agency shall have internal policies providing for retention of clinical records even if it discontinues operation (§I-9129.A.9).(LAC 48:I.9129 — Clinical Records (Minimum Standards for Home Health Agencies))
• 4A clinical note shall be written by the person making the visit and incorporated into the record within one week, containing date of visit, time of arrival and exit, services rendered/justification, signature of the person making the visit, vital signs per order or standard, and comments when indicated (§I-9129.B).(LAC 48:I.9129 — Clinical Records (Minimum Standards for Home Health Agencies))
• 5The agency shall obtain and retain a signed consent-for-treatment form and, when applicable, a signed release-of-information form (§I-9129.A.5-6).(LAC 48:I.9129 — Clinical Records (Minimum Standards for Home Health Agencies))
• 6Records shall be made available to LDH staff upon request and retained (paper or electronic) for at least six years from the date established, extended if involved in audit or litigation (§I-9129.A.7-8).(LAC 48:I.9129 — Clinical Records (Minimum Standards for Home Health Agencies))
• 7All entries shall be legible, clear, complete, dated, and authenticated by signature or secured computer entry with the primary author's unique identifier (§I-9129.A.2).(LAC 48:I.9129 — Clinical Records (Minimum Standards for Home Health Agencies))
• 8All clinical records shall be safeguarded against loss, destruction, and unauthorized use (§I-9129.A.4).(LAC 48:I.9129 — Clinical Records (Minimum Standards for Home Health Agencies))