SC Code of Regulations, Chapter 61, Section 77, Part 9 (Section 900): DHEC Standards for Licensing Home Health Agencies - Patient Record Requirements
As published by the South Carolina Legislature Online - Verified as current February 2016
SECTION 900
PATIENT RECORDS
Section 901 Content (II).
A. The content of the patient record will be determined by the home health agency, but must contain documentation needed to properly identify the patient and verify appropriate care rendered.
B. A comprehensive, patientspecific assessment shall be conducted at the time of admission for each patient, including, but not limited to: review of the drug regimen, pertinent medical data, psychosocial status, and functional limitations. The assessment shall be used in making individual treatment decisions and shall meet the patient’s medical, nursing, rehabilitative, social, and discharge planning needs; reassessment shall be accomplished based upon change in the patient’s condition.
C. A treatment plan shall be developed based on the interdisciplinary needs of the patient as determined by the assessment. The plan shall identify desired measurable clinical outcomes and the methods by which the outcomes are achieved through implementation of the plan. The treatment plan shall be approved by a physician or podiatrist and reviewed periodically at a frequency as determined by the agency but no later than every 62 days.
D. Patient records shall reflect services, treatment, and care provided directly to the patient by the agency or by another agency under contract, including patient progress, and descriptions of the planned clinical outcomes achieved.
E. Health care providers to whom patients are transferred or referred shall be provided transfer summaries and other appropriate information concerning the patient no later than two working days from the notification of the transfer in order to insure continuity of quality care.
Section 902 Record Maintenance.
A. Records of patients are the property of the home health agency and must not be removed from the agency’s patient record storage area, except for home visits, without court order.
B. The licensee must provide accommodations, space, supplies, and equipment adequate for the function, protection, and storage of patient records.
C. The patient record is confidential and may be made available only to authorized individuals. Active patient records, with the exception of records utilized by providers during home visits, must be available at the home health agency at all times and must be accessible by the staff member in charge, and by other authorized individuals such as representatives of the Department. (II)
D. Records generated by organizations/individuals contracted by the home health agency for services, treatment, or care shall be maintained by the home health agency that has admitted the patient.
E. The agency shall determine the medium in which information is stored.
F. Agencies employing electronic signatures or computergenerated signature codes shall insure authentication and security.
G. Upon discharge of a patient, the patient record shall be completed and filed in an inactive/closed file within a timeframe as determined by the home health agency but no later than 30 days after discharge. Closed patient records must be stored by the licensee and retained for 10 years following the discharge of the patient. Such records shall be made available to the Department upon request.
H. Prior to the closing of a home health agency for any reason, the licensee must arrange for preservation of records to insure compliance with these regulations. The licensee must notify the Department, in writing, describing these arrangements within 10 days of closure.
I. Patient records may be destroyed after 10 years provided that records of minors are retained until after the expiration of the period of election following achievement of majority as prescribed by statute.
J. In the event of change of ownership, all active patient records or copies of active patient records shall be transferred to the new owner(s).