Ind. Admin. Code tit. 410, r. 17-15-1 – Clinical records

Sec. 1. (a) Clinical records containing pertinent past and current findings in accordance with accepted professional standards shall be maintained for every patient as follows:

(1) The medical plan of care and appropriate identifying information.
(2) Name of the physician, dentist, chiropractor, podiatrist, or optometrist.
(3) Drug, dietary, treatment, and activity orders.
(4) Signed and dated clinical notes contributed to by all assigned personnel. Clinical notes shall be written the day service is rendered and incorporated within fourteen (14) days.
(5) Copies of summary reports sent to the person responsible for the medical component of the patient's care.
(6) A discharge summary.
(7) All entries must be legible, clear, complete, and appropriately authenticated and dated. Authentication must include signatures or a secured computer entry.

(b) Original clinical records shall be retained for the length of time as required by IC 16-39-7 after home health services are terminated by the home health agency. Policies shall provide for retention even if the home health agency discontinues operations.

(c) Clinical record information shall be safeguarded against loss or unauthorized use. Written procedures shall govern use and removal of records and conditions for release of information. Patient's written consent shall be required for release of information not authorized by law. Current service files shall be maintained at the parent or branch office from which the services are provided until the patient is discharged from service. Closed files may be stored away from the parent or branch office provided they can be returned to the office within seventy-two (72) hours. Closed files do not become current service files if the patient is readmitted to service.

(Indiana Department of Health; 410 IAC 17-15-1; filed Mar 18, 2002, 3:40 p.m.: 25 IR 2489; readopted filed Jul 14, 2008, 2:14 p.m.: 20080806-IR-410080322RFA; readopted filed Sep 10, 2014, 2:08 p.m.: 20141008-IR-410140299RFA; readopted filed Sep 10, 2020, 2:11 p.m.: 20201007-IR- 410200404RFA)