Section He-M 408.03 - Establishment of the Clinical Record(a) Each community mental health and residential program shall have a written clinical records policy that:(1) Outlines the content, maintenance, and monitoring requirements for its clinical records in both paper and electronic formats;(2) Addresses the completeness, accuracy, and timeliness of documentation;(3) Addresses confidentiality;(4) Stipulates how and when individuals may access their own records;(5) Addresses electronic signatures; and(6) Addresses electronic prescribing procedures.(b) Every individual shall have a clinical record that meets the requirements of He-M 408 and the program's policy.(c) The clinical record shall be: (1) Accessible to staff providing services;(2) Accessible to the individual or the parent or guardian if the individual is a minor or legally incompetent, unless otherwise prohibited by law; and(3) Available for supervisory and quality assurance activities conducted by the CMHP or the department of health and human services' bureau of mental health services.(d) If an individual, his or her guardian, an attorney or other advocate representing the individual, after review of the record, requests copies of the record, such copies in paper format, shall be made available free of charge for the first 25 pages and not more than 25 cents per page thereafter. If available, copies of records electronically stored and produced, shall be made available free of charge for the first 25 pages and at actual cost per page thereafter. The individual, his or her guardian, attorney or other advocate representing the individual may choose whether to receive the record in paper form or, if available, in electronic form.(e) Each documentation in the clinical record of a CMHP service shall include: (1) The signature of the service provider;(2) The service provider's credentials;(3) The legible name of the service provider including a typed name, name stamp, or printed name within proximity of the credentials and signature of the service provider;(4) The date of service; and(5) The date of documentation.(f) Documentation shall not be altered or changed by erasure or masking, such as through the use of liquid correction fluid. Corrections shall be made by drawing a line through the mistake. All corrections shall be signed and dated by the person making the change. Corrections to entries made in the electronic medical record shall clearly show the correction that was made, and the date, time, and name of the person making the correction.(g) Service documentation shall be completed prior to the service being billed.(h) The individual or guardian shall document informed consent for all planned services except as otherwise prohibited by law or where emergency treatment is indicated pursuant to RSA 135:21-b.(i) Clinical records shall be retained by a program or facility for 7 years after closure of a record for an adult and for 7 years beyond the age of 18 for a child.(j) Subcontracted service providers shall comply with all the provisions of He-M 408.N.H. Admin. Code § He-M 408.03
#2039, eff 7-1-82; ss by #2423, eff 7-13-83; rpld by #2468, eff 9-6-83
New. #3051, eff 7-8-85, EXPIRED: 7-8-91
New. #7281, eff 5-23-00, EXPIRED: 5-23-08
New. #9512, eff 7-9-09
Amended by Volume XXXVII Number 45, Filed November 09, 2017, Proposed by #12409, Effective 10/24/2017, Expires 10/24/2027.