N.H. Admin. Code § He-P 802.20

Current through Register No. 50, December 12, 2024

Section He-P 802.20 - Patient Records

(a) The licensee shall maintain a legible, current, and accurate record for each patient based on the services provided by the licensee.

(b) Patient records shall include, at a minimum:

(1) Identification data including the patient's:

a. Name;

b. Home address;

c. Home telephone number;

d. Name, address, and telephone number for an emergency contact person;

e. Date of birth;

f. Guardian or agent as applicable; and

g. Admitting diagnosis;

(2) A signed acknowledgment of receipt of patient bill of rights by the patient, guardian, agent, or surrogate decision maker;

(3) A written or electronic record of a health examination by a licensed practitioner;

(4) Written, dated, and signed orders of all medications, treatments, and therapeutic diets;

(5) Documentation of all services provided including signed progress notes by:

a. Nursing personnel;

b. Physicians; and

c. Other health professionals authorized by licensee policy;

(6) Orders and results of any laboratory, x-rays, consultations, or other diagnostic tests;

(7) The patient's health insurance information;

(8) The consent for release of information signed by the patient, guardian, or agent, if any;

(9) The medication record;

(10) Documentation of any accident or injuries occurring while in the care of the facility;

(11) Documentation of a patient's refusal of any care or services; and

(12) Transfer or discharge documentation including planning, referrals, and notification to the patient and guardian or agent if any.

(c) Patient records shall be available to authorized personnel and any other person authorized by law or rule to review such records.

(d) Patient records shall be retained, accessible, and stored in an area inaccessible to those who do not have authorized access to such records.

(e) The licensee shall create a policy to determine the method by which release of information from patient records shall occur.

(f) Patient records shall be safeguarded against loss or unauthorized use by implementation of appropriate use, handling, and storage procedures.

(g) Patient records shall be retained 7 years after discharge of a patient, and in the case of minors, patient records shall be retained until at least one year after reaching age 18, but in no case shall they be retained for less than 7 years after discharge.

(h) The licensee shall arrange for the storage of and access to medical records for 7 years in the event the hospital ceases operation.

(i) Electronic records shall be maintained according to current HIPAA regulations.

N.H. Admin. Code § He-P 802.20

#5846, eff 6-22-94, EXPIRED: 6-22-00

New. #9580, eff 10-24-09

Amended by Volume XXXVII Number 45, Filed November 09, 2017, Proposed by #12407, Effective 10/24/2017, Expires 4/22/2018.

Amended by Volume XLI Number 6, Filed February 11, 2021, Proposed by #13166, Effective 1/28/2021, Expires 1/28/2031.