N.H. Admin. Code § He-P 813.21

Current through Register No. 45, November 7, 2024

Section He-P 813.21 - Resident Records

(a) The family provider shall maintain on site a legible, current and accurate record for each resident based on services provided at the AFCR.

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

(1) A copy of the admissions contract and all documents required by He-P 813.15;

(2) Identification data, which shall include:

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

b. If a resident is present only for respite care as described in He-P 813.24, the resident's home address and phone number;

c. The resident's religious preference, if known;

d. The name, address and telephone number of an emergency contact person;

(3) The names and telephone numbers of the resident's licensed practitioners;

(4) The names, employers, business addresses, and telephone numbers of individuals contracted by the resident to provide services at the AFCR;

(5) Copies of all executed legal directives, such as durable power of attorney and living will;

(6) A record of the health examination(s) conducted by a licensed practitioner, which includes the information required by He-P 813.18(p) unless the licensed practitioner or resident documents refusal;

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

a. All medications;

b. Treatments; and

c. Special diets;

(8) All assessments and plans;

(9) Documentation that the resident or representative has participated in the development of the person-centered plan;

(10) All admission and progress notes;

(11) If services are provided at the AFCR by individuals not employed by the AFCR, documentation, which shall include:

a. The name of the agency providing the services;

b. The date services were provided; and

c. The name of the person providing the services;

(12) 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;

(13) Documentation of specialized care;

(14) Documentation of unusual incidents;

(15) The resident's or representative's consent for release of information;

(16) Transfer or discharge planning and referrals;

(17) Notification to the resident or representative of involuntary room change, transfer or discharge;

(18) The medication record, including:

a. The medication name, strength, dose, frequency and route of administration;

b. The date and time the medication was taken;

c. Effects of over the counter medications;

d. Documentation of medication errors or resident refusal to take the medication; and

e. Notice to the resident's licensed practitioner of any undesirable effects;

(19) Emergency data sheet, which contains the information required by He-P 813;

(20) Documentation of any resident refusal of care or services; and

(21) Documentation of nurse delegation as required by He-P 813.18(y) , if applicable.

(c) Resident records shall be available to:

(1) The resident;

(2) The AFCR and oversight agency staff as required by their job responsibilities;

(3) Any individual(s) given written authorization by the resident or representative; and

(4) The department and its agents.

(d) The family provider shall arrange for retention of and access to resident records for 6 years from the date the resident leaves the AFCR or for 4 years from the date the AFCR ceases operation.

N.H. Admin. Code § He-P 813.21

#8595, eff 4-1-06; ss by #9899-A, eff 3-29-11 (from He-P 813.22 )

Amended by Volume XXXIX Number 16, Filed April 18, 2019, Proposed by #12740, Effective 3/20/2019, Expires 9/16/2019.