Minnesota Administrative Rules

4664.0190 HEALTH INFORMATION MANAGEMENT.

Subpart 1.

Health information management.

A hospice provider must maintain health information management services, including clinical records, according to accepted professional standards and practices, federal regulations, and state statutes pertaining to content of the clinical record, health care data, computerization, confidentiality, retention, and retrieval. The clinical record must be readily accessible and systematically organized to facilitate retrieval. The hospice provider must maintain the records at the hospice provider's office site. For purposes of this part, "health information management" means the collection, analysis, and dissemination of data to support decisions related to patient care, effectiveness of care, reimbursement and payment, planning, research, and policy analysis.

Subp. 2.

Form of entries.

A hospice provider must ensure that entries in the clinical record are made for all hospice services provided. Documentation of hospice services must be created and signed by the staff person providing the service no later than the end of the work period. Entries must be legible, permanently recorded in ink, dated, and authenticated with the name and title of the person making the entry.

Subp. 3.

Content.

A hospice provider must ensure that each hospice patient's record contains:

A.

identification data and the name of the responsible person;

B.

the initial assessment and reassessments;

C.

the plan of care and any changes to the plan of care;

D.

pertinent medical history and allergies;

E.

complete documentation of all events and services provided directly and by contract, treatments, medications, and progress notes;

F.

documentation on the day of occurrence of any significant change in the patient's status or any significant incident and any actions by staff in response to the change or incident;

G.

a summary following the discontinuation of services, which includes the reason for the initiation and discontinuation of services and the patient's condition at the discontinuation of services;

H.

consent and authorization forms;

I.

a copy of the patient's health care directive, if executed and available;

J.

any complaints received, investigations, and resolutions;

K.

documentation identifying coordination with other persons or entities providing services, as required by part 4664.0170, subpart 3;

L.

documentation of tuberculosis screening of residential hospice patients; and

M.

any other information necessary to provide hospice care for each individual hospice patient.

Subp. 4.

Protection of information.

A hospice provider must safeguard clinical records against loss, destruction, and unauthorized use.

Subp. 5.

Confidentiality.

A hospice provider must not disclose to any other person any personal, financial, medical, or other information about a hospice patient, except as may be required or permitted by law. A hospice provider must establish and implement written procedures for security of hospice patient records, including:

A.

the use of patient records;

B.

the removal of patient records from the establishment; and

C.

the criteria for release of patient information.

Subp. 6.

Retention.

A hospice provider must retain a hospice patient's record for at least six years following the patient's discharge or discontinuation of services. A hospice provider must make arrangements for secure storage and retrieval of hospice patient records if the licensee ceases business.

Subp. 7.

Transfer.

If a hospice patient transfers to another hospice provider or other health care practitioner or provider or is admitted to an inpatient health care facility, a hospice provider, upon request of the hospice patient or as otherwise authorized by law, must send a copy or summary of the hospice patient's record to the new provider or facility or to the patient.

Subp. 8.

Fines.

For each violation of the following subparts, the stated fine shall be assessed:

A.

subpart 1, $100;

B.

subpart 2, $50;

C.

subpart 3, $100;

D.

subpart 4, $100;

E.

subpart 5, $250;

F.

subpart 6, $50; and

G.

subpart 7, $100.

Statutory Authority:

MS s 14.05; 14.3895; 144A.752

History:

28 SR 1639; 44 SR 371

Published Electronically:

September 16, 2019