NC DHHS

Pursuant to 10A NCAC 13J .1402 Content of Record: (a) if the agency is providing services to a client, the service record shall contain the following information (2)(c) a record of all services provided with entries with date and time of service and signed by the individual providing the service.

To demonstrate compliance with the above rule, the agency is responsible for capturing the required visit data below:

Date service provided

Duration and frequency of service provided

Tasks or details of care provided to the patient/client

In-Home Caregiver signature

If the home care agency uses a telephonic/electronic record keeping system, the agency’s policies and procedures shall outline the procedure for this type of record keeping and ensure that electronic signatures can be authenticated if needed. The Rules Governing Home Care Agencies in NC does not have a requirement for the patient signature to be included on the service log. The requirement for the patient signature is determined by the home care agency’s policy and procedures.