N.H. Admin. Code § He-P 805.19

Current through Register No. 45, November 7, 2024

Section He-P 805.19 - Resident Records

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

(b) At a minimum, resident records shall contain the following:

(1) A copy of the resident's residential service agreement and/or admission contract and all documents required by He-P 805.16(c) ;

(2) Notwithstanding (1) above, financial records may be kept in a separate file;

(3) Identification data, including:

a. Vital information including the resident's name, date of birth, and marital status;

b. If the individual is receiving respite care as described in He-P 805.20, the resident's home address and phone number;

c. Resident's religious preference, if known;

d. Residents veteran status, if known; and

e. Name, address and telephone number of an emergency contact person;

(4) The name and telephone number of the resident's licensed practitioner(s);

(5) For individuals contracted by the SRHCF or the resident to provide services at the SRHCF, their name, employer, business address and telephone number;

(6) Resident's health insurance information;

(7) Copies of any executed legal orders and directives, such as guardianship orders issued under RSA 464-A, a durable power of attorney for healthcare, or a living will;

(8) A record of the health assessment in accordance with He-P 805.16(m) and (n) ;

(9) Written, dated and signed orders for the following:

a. All medications, treatments and special diets; and

b. Laboratory services and consultations performed at the SRHCF;

(10) Results of any laboratory tests, X-rays or consultations performed at the SRHCF;

(11) All admission and progress notes;

(12) For services that are provided at the SRHCF by individuals who are not employed by the licensee, documentation shall include the name of the agency providing the services, the date services were provided, the name of the person providing services and a brief summary of the services provided;

(13) Documentation of any alteration in the resident's daily functioning such as:

a. Signs and symptoms of illness; and

b. Any action that was taken including practitioner notification;

(14) Documentation of medical or specialized care;

(15) Documentation of reportable incidents;

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

(17) Discharge planning and referrals;

(18) Transfer or discharge documentation, including notification to the resident, guardian or agent, if any, of involuntary room change, transfer or discharge, if applicable;

(19) The medication record as required by He-P 805.17(af) (4), (aj) and (ar) ;

(20) Information data sheet, which contains the information required by He-P 805.16(t) ;

(21) Documentation of nurse delegation as required by He-P 805.17(ai) ;

(22) Documentation of any accident or injuries occurring while in the care of the facility and requiring medical attention by a practitioner; and

(23) Documentation of a resident's refusal of any care or services.

(c) The licensee shall document evidence of immunization against influenza and pneumococcal disease for all consenting residents and shall provide to its consenting employees annual immunizations against influenza, to include:

(1) That immunizations shall be provided and reported in accordance with RSA 151:9-b, I-V; and

(2) The facility shall have a plan that identifies and documents, with dates, all residents and employees that have received or declined to receive immunizations.

(d) Resident records and resident information shall be kept confidential and only provided in accordance with law.

(e) The licensee shall develop and implement a written policy and procedure document that specifies the method by which release of information from a resident's record shall occur.

(f) When not being used by authorized personnel, resident records shall be safeguarded against loss or unauthorized use or access.

(g) Records shall be retained for 4 years after discharge, except that when the resident is a minor, records shall be retained until the person reaches the age of 19, but no less than 4 years after discharge.

(h) The licensee shall arrange for storage of, and access to, resident records as required by (g) above in the event the SRHCF ceases operation.

N.H. Admin. Code § He-P 805.19

#8746, eff 10-25-06

Amended byVolume XXXV Number 18, Filed May 7, 2015, Proposed by #10813, Effective 4/21/2015, Expires4/21/2025.