Requirements for the Establishment and Maintenance of Clinical Records in Comprehensive Care Facilities – 410 Ind. Admin. Code 16.2-3.1-50

Comprehensive Care Facilities must maintain clinical records on each resident.  These records must be maintained under the supervision of an employee of the facility designated with that responsibility.  The patient’s record must be complete, accurately documents, readily accessible and systematically organized.  Clinical records should be kept after discharge for a minimum of 1 year in the facility and 5 years total for adults, or until the patient reaches the age of 21 for minors.  The facility should safeguard clinical record information against loss, destruction or unauthorized use.  Finally, the facility should keep confidential all information contained in the resident’s records, regardless of the form or storage method.

Clinical records must contain sufficient information to identify the patient, a record of the resident’s assessments, the care plan and services provided, the results of any preadmission screening conducted by the state, and all progress notes.  Additionally, if a death occurs in the facility, information concerning the death must include notification of the physician, family, responsible person, and legal representative, the disposition of the body, personal possessions and medication, and a complete and accurate notation of the resident’s condition and most recent vital signs and symptoms preceding death.