Mont. Medicaid Hospice Policy Manual, Policy 707

CLINICAL

RECORDS

A clinical record containing past and current findings is maintained

for each hospice member. The clinical record must contain correct

clinical information that is available to the member’s attending

physician and hospice staff. The clinical record may be maintained

electronically.

CONTENT

Each member’s record must include the following:

1. The initial plan of care, updated plans of care, initial

assessment, comprehensive assessment, updated

comprehensive assessments, and clinical notes;

2. Signed copies of the notice of member’s rights and

election statement;

3. Responses to medications, symptom management,

treatments, and services;

4. Outcome measure data elements;

5. Physician certification and recertification of terminal

illness;

6. Any advance directives; and

7. Physician orders.

AUTHENTICATION

All entries must be legible, clear, complete, and appropriately

authenticated and dated in accordance with hospice policy and

currently accepted standards of practice.

PROTECTION

OF INFORMATION

The clinical record, its contents and the information contained

therein must be safeguarded against loss or unauthorized use.

The hospice must be in compliance with the Department's rules

regarding protection of personal health information.

RETENTION

OF RECORDS

Member clinical records must be retained for six years after the

death or discharge of the member, unless State law stipulates a

longer period of time. If the hospice discontinues operation, hospice

policies must provide for retention and storage of clinical records.

The hospice must inform its State agency and its CMS Regional

office where such clinical records will be stored and how they may

be accessed.

DISCHARGE OR

TRANSFER OF CARE

If the care of a member is transferred to another

Medicare/Medicaid-certified facility, the hospice must forward to the

receiving facility, a copy of:

1. The hospice discharge summary; and

2. The member's clinical record, if requested.

If a member revokes the election of hospice care, or is discharged

from hospice in accordance with Hospice Policy 406, the hospice

must forward to the member's attending physician, a copy of:

1. The hospice discharge summary; and

2. The member's clinical record, if requested.

The hospice discharge summary must include:

1. A summary of the member's stay including

treatments, symptoms and pain management;

2. The member's current plan of care;

3. The member's latest physician orders; and

4. Any other documentation that will assist in post-discharge continuity of care or that is requested by

the attending physician or receiving facility.

RETRIEVAL OF CLINICAL

RECORDS

The clinical record, whether hard copy or in electronic form, must

be made readily available on request by an appropriate authority.