Ga. Medicaid Part II Policies & Procedures for Hospice Services § 908

The hospice agency must establish and maintain a clinical record for everyone receiving care and

services. The record must be complete, accurately documented, readily accessible, and organized to

facilitate retrieval.

908.1. Each clinical record must be a comprehensive compilation of information regarding all

services provided. Clinical notes shall be written for all services provided after each

contact with the individual and must be signed and dated by the hospice discipline

providing care. Written notes should include all information pertaining to the member.

The record must include all services whether furnished directly or under arrangements

made by the hospice agency. Everyone’s record must contain at a minimum:

908.1.1. Identification data.

908.1.2. Initial and subsequent assessments.

908.1.3. Plan of Care.

908.1.4. Consent, authorization, election, transfer, discharge and/or revocation

forms.

908.1.5. Pertinent medical and psychosocial history.

908.1.6. Signed certifications of terminal illness.

908.1.7. A diagnosis and prognosis, including supporting medical data for the

terminal illness.

908.1.8. Complete documentation of all services and events including evaluation,

treatments, progress notes, etc.

908.1.9. Original written authorization for non-related hospice services in the

form of the Hospice Referral Form for Non-Hospice Related Services

and the documentation log of non-related services received; and

908.1.10. Documentation of problems/needs identified by the individual or family

member/caregiver.

The hospice agency must safeguard the individual’s record against loss, destruction and unauthorized

use and retain individual clinical records as original records in accordance with state licensure and

HIPAA regulations.