Section 246-335-110. Patient/client records.

(1) The licensee must:

(a) Maintain a current record for each patient or client consistent with chapter 70.02 RCW, Medical records—Health care information access and disclosure;

(b) Assure that the record is:

(i) Accessible, in an integrated document, in the licensee's office site for review by appropriate direct care personnel, volunteers, contractors, and the department;

(ii) Written legibly in permanent ink or retrievable by electronic means;

(iii) On the licensee's standardized forms;

(iv) In a legally acceptable manner;

(v) Kept confidential;

(vi) Chronological in its entirety or by the service provided;

(vii) Fastened together to avoid loss of record contents; and

(viii) Kept current with all documents filed according to agency time frames per agency policies and procedures;

(c) Include documentation of the following in each record, unless exempted in (d) of this subsection:

(i) Patient or client's name, age, current address and phone number;

(ii) Patient's or client's consent for service, care, and treatment;

(iii) Payment source and patient or client responsibility for payment;

(iv) Initial assessment when providing home health, hospice and hospice care center services, except when providing home health aide only services under WAC 246-335-080(5);

(v) Plan of care according to WAC 246-335-080, 246-335-085, 246-335-090, and 246-335-155(9), depending upon the service provided;

(vi) Signed or authenticated and dated notes documenting and describing services provided during each patient or client contact;

(vii) Observations and changes in the patient's or client's condition or needs;

(viii) For patients receiving home health, hospice and hospice care center services, with the exception of home health aide only services per WAC 246-335-080(5), authorized practitioner orders and documentation of response to medications and treatments ordered;

(ix) Supervision of home health aide and home care aide services according to WAC 246-335-095 (5)(b) and (c), 246-335-100 (5)(b), and 246-335-105(5); and

(x) Other documentation as required by this chapter;

(d) For patients receiving a one-time visit under WAC 246-335-080(3), 246-335-085(2) or 246-335-090(2), provide the documentation required in these sections;

(e) Consider the records as property of the licensee and allow the patient or client access to his or her own record; and

(f) Upon request and according to agency policy and procedure, provide patient or client information or a summary of care when the patient or client is transferred or discharged to another agency or facility.

(2) The licensee must maintain records for:

(a) Adults—Three years following the date of termination of services; and

(b) Minors—Three years after attaining age eighteen, or five years following discharge, whichever is longer.

(3) The licensee must:

(a) Store records to prevent loss of information and to maintain the integrity of the record and protect against unauthorized use;

(b) Maintain or release records after a patient's or client's death according to chapter 70.02 RCW, Medical records—Health care information access and disclosure; and

(c) After ceasing operation, retain or dispose of records in a confidential manner according to the time frames in subsection (2) of this section.

[Statutory Authority: Chapter 70.127 RCW. WSR 02-18-026, § 246-335-110, filed 8/23/02, effective 10/1/02.]

Chapter 70.127 RCW. WSR 02-18-026, § 246-335-110, filed 8/23/02, effective 10/1/02.

Rules

246-335-080,246-335-080,246-335-085,246-335-090,246-335-155,246-335-080,246-335-095,246-335-100,246-335-105,246-335-080,246-335-085,246-335-090,