[Code of Federal Regulations]

[Title 42, Volume 2]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR418.74]



[Page 920]

 

                         TITLE 42--PUBLIC HEALTH

 

                    CHAPTER IV--CENTERS FOR MEDICARE

                          & MEDICAID SERVICES,

                        DEPARTMENT OF HEALTH AND

                             HUMAN SERVICES

 

PART 418_HOSPICE CARE--Table of Contents

 

      Subpart C_Conditions of Participation_General Provisions and 

                             Administration

 

Sec. 418.74  Condition of participation--Central clinical records.



    In accordance with accepted principles of practice, the hospice must 

establish and maintain a clinical record for every individual receiving 

care and services. The record must be complete, promptly and accurately 

documented, readily accessible and systematically organized to 

facilitate retrieval.

    (a) Standard: Content. Each clinical record is a comprehensive 

compilation of information. Entries are made for all services provided. 

Entries are made and signed by the person providing the services. The 

record includes all services whether furnished directly or under 

arrangements made by the hospice. Each individual's record contains--

    (1) The initial and subsequent assessments;

    (2) The plan of care;

    (3) Identification data;

    (4) Consent and authorization and election forms;

    (5) Pertinent medical history; and

    (6) Complete documentation of all services and events (including 

evaluations, treatments, progress notes, etc.).

    (b) Standard; Protection of information. The hospice must safeguard 

the clinical record against loss, destruction and unauthorized use.