N.H. Admin. Code § He-P 824.17

Current through Register No. 50, December 12, 2024

Section He-P 824.17 - Patient Records

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

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

(1) A copy of the patient's service agreement and/or admission contract and all documents required by He-P 824.16(c)(1);

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

(3) Identification data, including:

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

b. Patient's religious preference, if known;

c. Patient's veteran status, if known; and

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

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

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

(6) Patient'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 824.16(e)(1);

(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 HH;

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

(11) All admission and progress notes;

(12) For services that are provided at the HH 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 medical or specialized care;

(14) Documentation of reportable incidents;

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

(16) The medication record as required;

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

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

(19) The licensee shall arrange for and document the immunization of all consenting patients for pneumococcal disease, as applicable, and all consenting patients for influenza in accordance with RSA 151:9-b and report immunization data to the department's immunization program.

(c) Patient records and patient information shall be kept confidential and only provided in accordance with 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 patient's record shall occur.

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

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

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

N.H. Admin. Code § He-P 824.17

#9317, eff 11-8-08

Amended by Volume XXXVII Number 19, Filed May 11, 2017, Proposed by #12169, Effective 4/29/2017, Expires 10/26/2017.

Amended by Number 15, Filed April 13, 2023, Proposed by #13572, Effective 3/1/2023, Expires 3/1/2033.