(a) The home care provider must maintain records for each client for whom it is providing services. Entries in the client records must be current, legible, permanently recorded, dated, and authenticated with the name and title of the person making the entry.
(b) Client records, whether written or electronic, must be protected against loss, tampering, or unauthorized disclosure in compliance with chapter 13 and other applicable relevant federal and state laws. The home care provider shall establish and implement written procedures to control use, storage, and security of client's records and establish criteria for release of client information.
(c) The home care provider may not disclose to any other person any personal, financial, medical, or other information about the client, except:
(1) as may be required by law;
(2) to employees or contractors of the home care provider, another home care provider, other health care practitioner or provider, or inpatient facility needing information in order to provide services to the client, but only such information that is necessary for the provision of services;
(3) to persons authorized in writing by the client or the client's representative to receive the information, including third-party payers; and
(4) to representatives of the commissioner authorized to survey or investigate home care providers under this chapter or federal laws.
The home care provider must ensure that the appropriate records are readily available to employees or contractors authorized to access the records. Client records must be maintained in a manner that allows for timely access, printing, or transmission of the records.
Contents of a client record include the following for each client:
(1) identifying information, including the client's name, date of birth, address, and telephone number;
(2) the name, address, and telephone number of an emergency contact, family members, client's representative, if any, or others as identified;
(3) names, addresses, and telephone numbers of the client's health and medical service providers and other home care providers, if known;
(4) health information, including medical history, allergies, and when the provider is managing medications, treatments or therapies that require documentation, and other relevant health records;
(5) client's advance directives, if any;
(6) the home care provider's current and previous assessments and service plans;
(7) all records of communications pertinent to the client's home care services;
(8) documentation of significant changes in the client's status and actions taken in response to the needs of the client including reporting to the appropriate supervisor or health care professional;
(9) documentation of incidents involving the client and actions taken in response to the needs of the client including reporting to the appropriate supervisor or health care professional;
(10) documentation that services have been provided as identified in the service plan;
(11) documentation that the client has received and reviewed the home care bill of rights;
(12) documentation that the client has been provided the statement of disclosure on limitations of services under section 144A.4791, subdivision 3;
(13) documentation of complaints received and resolution;
(14) discharge summary, including service termination notice and related documentation, when applicable; and
(15) other documentation required under this chapter and relevant to the client's services or status.
If a client transfers to another home care provider or other health care practitioner or provider, or is admitted to an inpatient facility, the home care provider, upon request of the client or the client's representative, shall take steps to ensure a coordinated transfer including sending a copy or summary of the client's record to the new home care provider, the facility, or the client, as appropriate.
Following the client's discharge or termination of services, a home care provider must retain a client's record for at least five years, or as otherwise required by state or federal regulations. Arrangements must be made for secure storage and retrieval of client records if the home care provider ceases business.
Copyright © 2015 by the Revisor of Statutes, State of Minnesota. All rights reserved.