(a)

1. (1) In accordance with accepted principles of practice, the hospice shall establish and maintain a clinical record for every patient receiving care and services.

2. (2) The record shall be:

   1. (A) Complete;
   2. (B) Accurate;
   3. (C) Readily accessible; and
   4. (D) Systematically organized to facilitate retrieval.

(b) Content.

1. (1) Entries shall be:

   1. (A) Made for the day services are provided; and
   2. (B) Filed within seven (7) days.
2. (2) Entries shall be signed by the person providing the services.
3. (3) All entries shall be legible and readily accessible.
4. (4) The record shall include all services, whether furnished directly or under arrangement.

5. (5) Each patient’s record shall contain the following:

   1. (A) Initial and subsequent assessments;
   2. (B) Plan of care;
   3. (C) Identification data;
   4. (D) Consent, authorization, and election forms;
   5. (E) Pertinent medical history; and
   6. (F) Documentation of all services and events.

(c) Protection of information. The hospice shall use reasonable precautions to safeguard the clinical record against:

1. (1) Loss;
2. (2) Destruction; and
3. (3) Unauthorized use.