42 C.F.R. § 418.74 Condition of participation—Central clinical records.
Title 42 - Public Health
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.
Title 42: Public Health
PART 418—HOSPICE CARE
Subpart C—Conditions of Participation—General Provisions and Administration
§ 418.74 Condition of participation—Central clinical records.
