SECTION 310:661-3-3. Medical records

(a)   The hospice shall establish and maintain a medical record for each individual receiving care and services. The record shall be complete, timely and accurately documented, and readily accessible.

(b)   The medical record shall contain sufficient information to justify the diagnosis and warrant the treatment and services provided. Entries are made and signed by the person providing the services. The record shall include all care and services whether furnished directly or under arrangements by the hospice. Each record shall contain at least, but not be limited to, the following:

(1)   Identification data.

(2)   Initial and subsequent assessments.

(3)   Plan of care.

(4)   Consent, authorization and election forms.

(5)   Medical history.

(6)   Complete documentation of all care, services and events including evaluations, treatments, progress notes, laboratory and x-ray reports, and discharge summary.

(c)   The hospice shall safeguard the medical record against loss, destruction, and unauthorized use.

(d)   Current records shall be completed promptly. A plan of care shall be completed within forty-eight (48) hours following admission. Records of discharged patients shall be completed within thirty (30) days following discharge.

(e)   Medical records shall be retained at least five (5) years beyond the date the patient was last seen or at least three (3) years beyond the date of the patient's death.

(f)   A hospice may microfilm medical records in order to conserve space. Records reconstituted from microfilm shall be considered the same as the original and retention of the microfilmed record constitutes compliance with preservation laws.

(g)   The hospice shall advise the Department in writing at the time of cessation of operation as to where hospice records shall be archived and how these records shall be accessed.

[Source: Added at 9 Ok Reg 1985, eff 6-11-92; Amended at 14 Ok Reg 2106, eff 4-7-97 (emergency); Amended at 14 Ok Reg 2269, eff 6-12-97]