N.H. Admin. Code § He-P 826.19

Current through Register No. 50, December 12, 2024

Section He-P 826.19 - Client Records

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

(b) Client records shall contain the following:

(1) A copy of the client's service agreement and all documents required by He-P 826.16(c);

(2) Identification data, including:

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

b. Religious preference, if any; and

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

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

(4) Contact information for the person referring the client for services, as applicable;

(5) The name, address, and telephone number of the behavioral health care provider, if applicable;

(6) The client'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 examination(s) in accordance with He-P 826.16(o) and (p);

(9) 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 SUD-RTF;

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

(11) All evaluations and treatment plans, including documentation that the client and the guardian, agent, or surrogate decision-maker, if any, has participated in the development of the care and treatment plans;

(12) All admission and progress notes;

(13) If services are provided at the SUD-RTF 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;

(14) 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;

(15) Documentation of any medical or specialized care;

(16) Documentation of unusual incidents;

(17) The consent for release of information signed by the client, guardian, agent, or surrogate decision-maker, if any;

(18) Discharge summary, planning, and referrals;

(19) 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;

(20) The information required by He-P 826.16(k) as applicable;

(21) Information data sheet, which contains the information required by He-P 826.16(s);

(22) Release of information sheet;

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

(24) 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 42 CFR Part 2, 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. For all SUD-RTF facilities, this shall include compliance with 42 CFR Part 2.

(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 clients and personnel that include:

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

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

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

(g) Records shall be retained for at least 7 years after discharge, except that when the client is a minor, records shall, in addition, be retained 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 SUD-RTF ceases operation.

N.H. Admin. Code § He-P 826.19

Derived From Volume XXXVIII Number 45, Filed November 8, 2018, Proposed by #12658, Effective 11/1/2018, Expires 11/1/2028.