Patient/Client Records - 10-144-119 Me. Code R. § 7.F

Each patient utilizing a home health care service must have an identifiable clinical record that is maintained by the service provider.  The record should contain such information as appropriate identifying information, a medication list, a care plan, periodic assessments of the patient, and summary notes of the care provided.  The record must also include documentation that the patient has been shown his or her rights and was informed of the consumer telephone hotline. A patient’s records are to be made available to the Department of Health and Human Services for examination and copy at no expense to the Department.