Minnesota Administrative Rules

4668.0160 CLIENT RECORDS.

Subpart 1.

Maintenance of client record.

The licensee shall maintain a record for each client.

Subp. 2.

Security.

The licensee shall establish written procedures to control use and removal of client records from the provider's offices and for security in client residences and to establish criteria for release of information. The client record must be readily accessible to personnel authorized by the licensee to use the client record.

Subp. 3.

Retention.

A client's record must be retained for at least five years following discharge. Arrangements must be made for secure storage and retrieval of client records if the licensee ceases business.

Subp. 4.

Transfer of client.

If a client transfers to another home care provider, other health care practitioner or provider, or is admitted to an inpatient facility, the licensee, upon request of the client, shall send a copy or summary of the client's record to the new provider or facility or to the client.

Subp. 5.

Form of entries.

All entries in the client record must be:

A.

legible, permanently recorded in ink, dated, and authenticated with the name and title of the person making the entry; or

B.

recorded in an electronic media in a secure manner.

Subp. 6.

Content of client record.

The client record must contain:

A.

the following information about the client:

(1)

name;

(2)

address;

(3)

telephone number;

(4)

date of birth;

(5)

dates of the beginning and end of services; and

(6)

names, addresses, and telephone numbers of any responsible persons;

B.

a service agreement as required by part 4668.0140;

C.

medication and treatment orders, if any;

D.

notes summarizing each contact with the client in the client's residence, signed by each individual providing service including volunteers, and entered in the record no later than two weeks after the contact;

E.

names, addresses, and telephone numbers of the client's medical services providers and other home care providers, if known; and

F.

a summary following the termination of services, which includes the reason for the initiation and termination of services, and the client's condition at the termination of services.

Class C licensees need only include the information required by items A, B, and E. Class E licensees need only include the information required by items A, B, D, and E.

Subp. 7.

Confidentiality.

The licensee shall not disclose to any other person any personal, financial, medical, or other information about the client, except:

A.

as may be required by law;

B.

to staff, contractors of the licensee, another home care provider, other health care practitioner or provider, or inpatient facility who require information in order to provide services to the client, but only such information that is necessary to the provision of services;

C.

to persons authorized in writing by the client or the client's responsible person to receive the information, including third-party payers; and

D.

representatives of the commissioner authorized to survey or investigate home care providers.

Statutory Authority:

MS s 144A.45; 144A.46; 144A.47; 144A.48

History:

17 SR 2454

Published Electronically:

October 2, 2013