Section 410IAC16.2-3.1-50. Clinical records

   (a) The facility 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. Any consultation must be provided by a medical records practitioner in accordance with accepted professional standards and practices. The records must be as follows:

(1) Complete.

(2) Accurately documented.

(3) Readily accessible.

(4) Systematically organized.

  (b) Clinical records must be retained after discharge for:

(1) a minimum period of one (1) year in the facility and five (5) years total; or

(2) for a minor, until twenty-one (21) years of age.

  (c) If a facility ceases operation, the director shall be informed within three (3) business days by the licensee of the arrangements made for the preservation of the residents' clinical records.

  (d) The facility must safeguard clinical record information against loss, destruction, or unauthorized use.

  (e) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is required by one (1) or more of the following:

(1) Transfer to another health care institution.

(2) Law.

(3) Third party payment contract.

(4) The resident or legal representative.

  (f) The clinical record must contain the following:

(1) Sufficient information to identify the resident.

(2) A record of the resident's assessments.

(3) The care plan and services provided.

(4) The results of any preadmission screening conducted by the state.

(5) Progress notes.

  (g) Each facility shall have a well-defined policy that ensures the staff has sufficient progress information to meet the residents' needs.

  (h) A transfer form shall include:

(1) Identification data.

(2) Name of the transferring institution.

(3) Name of the receiving institution and date of transfer.

(4) Resident's personal property.

(5) Nurses' notes relating to the resident's:

(A) functional abilities and physical limitations;

(B) nursing care;

(C) medications;

(D) treatment;

(E) current diet; and

(F) condition on transfer.

(6) Diagnosis.

(7) Presence or absence of decubitus ulcer.

(8) Date of chest x-ray and skin test for tuberculosis.

  (i) Current clinical records shall be completed promptly and those of discharged residents shall be completed within seventy (70) days of the discharge date.

  (j) If a death occurs, information concerning the resident's death shall include the following:

(1) Notification of the physician, family, responsible person, and legal representative.

(2) The disposition of the body, personal possessions, and medications.

(3) A complete and accurate notation of the resident's condition and most recent vital signs and symptoms preceding death.

  (k) For purposes of IC 16-28-5-1, a breach of:

(1) subsection (a), (d), (e), (f), (g), (h), or (j) is a noncompliance; and

(2) subsection (b), (c), or (i) is a nonconformance.

(Indiana State Department of Health; 410 IAC 16.2-3.1-50; filed Jan 10, 1997, 4:00 p.m.: 20 IR 1559, eff Apr 1, 1997; errata, 20 IR 1738; errata filed Apr 10, 1997, 12:15 p.m.: 20 IR 2414; readopted filed Jul 11, 2001, 2:23 p.m.: 24 IR 4234; readopted filed May 22, 2007, 1:44 p.m.: 20070613-IR-410070141RFA; readopted filed Sep 11, 2013, 3:19 p.m.: 20131009-IR-410130346RFA)