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(1) Each home infusion therapy agency, and any contracted party providing services to the patient, together, shall establish and maintain for each patient accepted for care, a home care record which must include the following information:

(a) admission data, including the:

(i) name;

(ii) current address;

(iii) date of birth;

(iv) sex;

(v) date of admission;

(vi) name, address and telephone number of the patient's caregiver or family member;

(vii) name, address and telephone number of the pharmacist-in-charge and the prescribing practitioner; and

(viii) admission diagnosis or pertinent health information.

(b) a notation of patient conditions and diagnoses which are relevant to the plan of care;

(c) any allergies and known adverse reactions to drugs and food. This information must be given such prominence in the record so as to make it obvious to any persons who provide food or medication to the patient;

(d) laboratory reports, if applicable; and

(e) documentation that a list of patient rights and responsibilities have been made available to each patient or the patient's caregiver.

(2) The responsibilities of the patient, the home infusion therapy agency, including any contracted parties, and the prescribing practitioner, in the areas of delivery of care and monitoring of the patient, must be clearly documented in the patient's home care record.

(3) The home infusion therapy agency, and any contracted party providing services to the patient, together, shall develop a plan of care within three working days of the initiation of therapy, which must include:

(a) a diagnosis;

(b) the types of services and equipment required;

(c) the access device and route of administration;

(d) the estimated length of service;

(e) a statement of treatment goals;

(f) the regimen and prescription ordered;

(g) the concurrent legend and over the counter drugs;

(h) an assessment of mental status;

(i) permitted activities;

(j) the prognosis, discharge, transfer or referral plan; and

(k) instructions to patient and family.

History: Sec. 50-5-103, MCA; IMP, Sec. 50-5-103 and 50-5-213, MCA; NEW, 1996 MAR p. 2587, Eff. 10/4/96; TRANS, from DHES, 2002 MAR p. 185.

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