N.H. Admin. Code § He-P 807.19

Current through Register No. 50, December 12, 2024

Section He-P 807.19 - Client Records

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

(b) Client records shall contain the following:

(1) A copy of the client's service agreement and all documents required by He-P 807.16(c) ;

(2) Identification data, including:

a. Vital information including the client's name;

b. Home address;

c. Home telephone number;

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

e. Date of birth, and

f. Guardian, agent, or surrogate decision-maker where applicable.

(3) The name and telephone number of the client's licensed practitioner(s);

(4) The client's health insurance information;

(5) 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;

(6) A record of the health examination(s) in accordance with He-P 807.16(m) and (o) ;

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

a. All medications, treatments, and special diets, as applicable; and

b. Laboratory services and consultations performed at the RTRF;

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

(9) All evaluations, assessments, and treatment plans, including documentation that the client and the guardian or agent, if any, has participated in the development of the care and treatment plans;

(10) All admission and progress notes;

(11) If services are provided at the RTRF by individuals not employed by the licensee, documentation that includes 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;

(12) Documentation of any alteration in the client's daily functioning such as:

a. Signs and symptoms of illness; and

b. Any action that was taken including practitioner notification;

(13) Documentation of any medical or specialized care;

(14) Documentation of reportable incidents;

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

(16) Discharge summary, planning, and referrals;

(17) Transfer or discharge documentation, including notification to the client, guardian, agent, or surrogate decision-maker, if any, of involuntary room change, transfer or discharge, if applicable;

(18) The information required by He-P 807.17(ai) as applicable;

(19) Information data sheet, which contains the information required by He-P 807.16(s) ;

(20) Documentation of nurse delegation of medications as required by the nurse practice act, as applicable; and

(21) Documentation of a client's refusal of any care or services.

(c) Client records and client information shall be kept confidential and only provided in accordance with HIPAA, or any other applicable provision of law.

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

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

(f) Any licensee that maintains electronic records shall develop written policies and procedures designed to protect the privacy of residents and personnel that, at a minimum, include:

(1) Procedures for backing up files to prevent loss of data;

(2) Safeguards for maintaining the confidentiality of information pertaining to residents and staff; and

(3) Systems to prevent tampering with information pertaining to residents and staff.

(g) Records shall be retained for at least 7 years after discharge, except that when the client is a minor, records shall be retained for at least 7 years after the minor reaches the age of majority.

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

N.H. Admin. Code § He-P 807.19

#9873-A, eff 2-24-11

Amended by Volume XXXIX Number 10, Filed March 7, 2019, Proposed by #12727, Effective 2/20/2019, Expires 8/19/2019.

Derived from Volume XL Number 2, Filed January 9, 2020, Proposed by #12962, Effective 12/31/2019, Expires 12/31/2029.