Clinical records - 28 Pa. Code § 601.36

Providers of home health care services must maintain a clinical record containing pertinent past and current findings for every patient receiving services.  The record must contain the following information:

•         Plan of treatment;
•         Appropriate identifying information;
•         Name of physician;
•         Drug and dietary treatment;
•         Activity orders;
•         Signed and dated clinical and progress notes;
•         Copies of summary reports;
•         Discharge summary.

Clinical records must be retained for seven years after discharge of the patient; if the patient is transferred to another home health care agency, a copy of the record or abstract must accompany the patient.  Information contained in the patient’s record is privileged and confidential.  Clinical record information must be safeguarded against loss or unauthorized use.  The records may be disclosed to authorized personnel, upon written authorization by the patient or as otherwise permitted by law.