Page 350

7 AAC 12.561. Clinical records. (a) A home health agency shall maintain a clinical record for each patient. The clinical record must be legible and maintained in accordance with accepted professional or occupational standards. The clinical record must be readily available upon the request of the

(1) attending physician, advanced practice registered nurse, or physician assistant;

(2) the department;

(3) the patient;

(4) the patient’s representative; or

(5) if authorized by the patient, another health care provider. (b) A clinical record must include the following items:

(1) appropriate identifying information;

(2) assessments by appropriate personnel;

(3) the plans of care;

(4) name of the attending physician, advanced practice registered nurse, or physician assistant;

(5) signed and dated clinical progress notes;

(6) copies of summary reports sent to the attending physician, advanced practice registered nurse, or physician assistant;

(7) a signed patient release or consent forms, if indicated;

(8) documentation of informed consent regarding the initiation of care and treatment, and changes in the plan of care;

(9) evidence the patient received the patients’ rights under 7 AAC 12.534 and advance directive information under 7 AAC 12.537;

(10) copies of transfer information sent with the patient; and

(11) a discharge summary. (c) Clinical progress notes must be written or dictated on the day that care or service is rendered. The clinical progress notes must be incorporated into the patient’s clinical record within seven days. Summaries of the care or service reported must be submitted to the attending physician, advanced practice registered nurse, or physician assistant at least every 62 days. (d) A home health agency shall have written policies and procedures to provide that clinical