N.D. Admin. Code 33-03-35-09

Current through Supplement No. 395, January, 2025

Section 33-03-35-09 - Patient records

1. The facility shall keep accurate, current, and confidential records of all patients.

2. The facility shall provide for secure maintenance and storage of all patient records.

3. Patient records must include:

a. Complete identification of each patient, including information on the patient's next of kin and responsible person.

b. Initial and subsequent assessments of each patient.

c. The current person-centered care plan.

d. The current hospice care plan.

e. Complete documentation of all services rendered.

f. An admission note.

g. A medication administration record documenting medication administration consistent with applicable state laws, rules, and practice acts.

h. Consent and authorization forms.

i. A discharge note, including disposition of the patient's personal effects, money, or valuables deposited with the facility.

4. The facility shall maintain patient records for a period of not less than five years from the date of discharge or death.

N.D. Admin Code 33-03-35-09

Adopted by Administrative Rules Supplement 2023-388, April 2023, effective 4/1/2023.

General Authority: NDCC 23-17.7-03

Law Implemented: NDCC 23-17.7-03