N.M. Admin. Code § 8.370.22.34

Current through Register Vol. 35, No. 23, December 10, 2024

Section 8.370.22.34 - PATIENT/CLIENT RECORDS

Each agency licensed pursuant to these regulations must maintain the original record for each patient/client receiving services. Patient/client records shall be made available for review upon request of the licensing authority. Every record must be accurate, legible, promptly completed and consistently organized. A patient/client record must meet the following criteria:

A. Content of patient/client record:

(1) Medically directed patient/client record must include:

(a) past and current medical findings in accordance with accepted professional standard;

(b) plan of care;

(c) identifying information;

(d) name of physician;

(e) medications, diet, treatment/services, and activity orders;

(f) signed and dated notes on the day service(s) provided;

(g) copies of summary reports sent to the physician;

(h) evidence of patient/client being informed of rights;

(i) evidence of coordination of care provided by all personnel providing patient/client services;

(j) discharge summary.

(2) Non-medically directed patient/client records must include:

(a) plan of care;

(b) identifying information;

(c) signed and dated notes on the day service(s) provided;

(d) evidence of patient/client being informed of rights;

(e) evidence of coordination of care of all personnel providing patient/client services;

(f) evidence of discharge.

B. If the patient/client is discharged or transferred to another provider of health care, upon receipt of a signed request from the patient/client, a copy of the original record or an abstract of the same must be made available to the receiving facility, within 24 hours.

C. Protection of patient/client records:

(1) The agency must insure that the original patient/client records and information is safeguarded against loss or unauthorized use.

(2) The agency must have written policies and procedures governing the use and removal of patient/client records and conditions for release of information.

(3) patient/client's written consent is required for release of information not authorized by law.

D. Retention of patient/client records:

(1) Original patient/client records shall be retained for at least 10 years after the patient/client is discharged.

(2) Original patient/client records shall be maintained for the requisite period even if the agency has discontinued operations.

(3) The licensing authority must be notified, in writing, prior to discontinuing operation of the storage location of patient/client records.

N.M. Admin. Code § 8.370.22.34

Adopted by New Mexico Register, Volume XXXV, Issue 12, June 25, 2024, eff. 7/1/2024