Sec.19-13-D75. Clinical record system

(a) An agency shall maintain a clinical record system which includes, but not limited to:

(1) A written policy on the protection of records which defines procedures governing the use and removal of records, conditions for release of information contained in the record and which requires authorization in writing by the patient for release of appropriate information not otherwise authorized by law;

(2) A written policy which provides for the retention and storage of records for at least seven (7) years from the date of the last service to the patient and which provides for the retention and storage of such records in the event the agency discontinues operation;

(3) A policy and procedure manual governing the record system and procedures for all agency staff;

(4) Maintaining records on the agency's premises in lockable storage area(s).

(b) A clinical record shall be developed for each patient which shall be filed in an accessible area within the agency and which shall include, but not be limited to:

(1) Identifying data (name, address, date of birth, sex, date of admission or readmission);

(2) Source of referral, including where applicable, name and type of institution from which discharged and date of discharge;

(3) Patient care plans;

(4) Name, address and phone number of physician(s) or dentist(s) responsible for medical or dental care;

(5) Pertinent past and current health history;

(6) Clinical notes following each patient's contact with the staff members, incorporated no less often than weekly;

(7) Progress notes by professional staff and copies of summary or progress reports sent to physician or dentist;

(8) Documentation of all case management and monitoring activities, including sixty (60) day utilization review;

(9) Discharge summary, if applicable.

(c) All notes and reports in the patient's clinical record shall be typewritten or legibly written in ink, dated and signed by the recording person with his full name or first initial and surname and title.

(Effective September 20, 1978)