SECTION 310:662-3-5. Clinical records

(a)   The agency shall establish and maintain a clinical record for each client receiving care and services. The record shall be complete, timely, accurately documented and readily accessible. Clinical records shall be kept confidential. The agency shall ensure confidentiality of client information in accordance with written policies and procedures. Records shall be stored in a locked area and only authorized personnel shall have access to the records.

(b)   Clinical records are the property of the home care agency and may be released only upon the written consent of the client, the court appointed guardian, by a court order, or as otherwise authorized by law. Any person who has been a client of a home care agency shall be entitled to obtain copies of their clinical record as allowed by law. [76 O.S. 1991, §19]

(c)   Clinical records shall be retained at least five (5) years beyond the date the client was last seen or longer as otherwise required by law.

(d)   In addition to a plan of care, the clinical record shall contain:

(1)   Appropriate identifying information for the client, household members and/or client representative(s), including telephone numbers to be used in the event of an emergency.

(2)   Initial assessment including health history, and current findings.

(3)   A description of the client's functional limitations and activity restrictions, if any.

(4)   Documentation of any change in the client's condition.

(5)   Notes for each service provided including the date, service provided, and the name and title of the person providing the service and the person's signature.

(e)   If skilled care is provided or if personal care is provided by an order of a physician, the clinical record shall also contain:

(1)   The name of the client's physician and telephone number.

(2)   Signed and dated clinical notes which accurately document services provided, treatments and/or medications administered and client response to the services provided.

(3)   Physician orders which shall be sent by the agency within ten (10) days to the ordering physician to be signed and returned in a timely manner.

(4)   Upon discharge, a summary of the services provided and the resulting status of the client at the time of discharge. A copy of the discharge summary shall be provided to the client's physician.

[Source: Added at 11 Ok Reg 3185, eff 6-27-94; Amended at 14 Ok Reg 2111, eff 4-7-97 (emergency); Amended at 14 Ok Reg 2274, eff 6-12-97]