[Code of Federal Regulations]

[Title 42, Volume 3]

[Revised as of October 1, 2005]

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

[CITE: 42CFR484.48]



[Page 587]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 484_HOME HEALTH SERVICES--Table of Contents

 

                    Subpart C_Furnishing of Services

 

Sec. 484.48  Condition of participation: Clinical records.



    A clinical record containing pertinent past and current findings in 

accordance with accepted professional standards is maintained for every 

patient receiving home health services. In addition to the plan of care, 

the record contains appropriate identifying information; name of 

physician; drug, dietary, treatment, and activity orders; signed and 

dated clinical and progress notes; copies of summary reports sent to the 

attending physician; and a discharge summary. The HHA must inform the 

attending physician of the availability of a discharge summary. The 

discharge summary must be sent to the attending physician upon request 

and must include the patient's medical and health status at discharge.

    (a) Standards: Retention of records. Clinical records are retained 

for 5 years after the month the cost report to which the records apply 

is filed with the intermediary, unless State law stipulates a longer 

period of time. Policies provide for retention even if the HHA 

discontinues operations. If a patient is transferred to another health 

facility, a copy of the record or abstract is sent with the patient.

    (b) Standards: Protection of records. Clinical record information is 

safe-guarded against loss or unauthorized use. Written procedures govern 

use and removal of records and the conditions for release of 

information. Patient's written consent is required for release of 

information not authorized by law.



[54 FR 33367, Aug. 14, 1989, as amended at 60 FR 65498, Dec. 20, 1994]