Central clinical record – Ohio Admin. Code 3701-19-23

Each hospice care program must establish and maintain a central clinical record for each patient receiving care and services from the program. All services, whether furnished by employees, persons under contract, or volunteers, shall be documented in the clinical record, and the record must contain the following additional information:

• Identification data;
• Pertinent medical history, including the physician’s diagnosis of terminal illness;
• Consent and authorization forms;
• Initial and subsequent assessments, including evaluations of physical, psychosocial, and spiritual needs and the need for volunteer and bereavement services;
• The interdisciplinary plan of care;
• Documentation of all services and events;
• A statement of whether or not an adult patient has prepared an advanced directive; and
• Transfer and discharge summaries.

The hospice care program must provide for storage of the central clinical records to protect them against loss, destruction, and unauthorized use, and must have policies and procedures to ensure the confidentiality of the records.  Hospice programs that maintain a patient’s clinical record electronically must use an electronic signature system that meets applicable requirements; electronic records must be accessible to the director of health during inspections.