Current through Register Vol. 51, No. 19, September 20, 2024
A. Records for
all Residents. Records for all residents shall be maintained in accordance with
accepted professional standards and practices.
B. Contents of Record. Contents of record
shall include:
(1) Identification and summary
sheet or sheets including:
(a) Resident's
name;
(b) Social Security
number;
(c) Armed forces
status;
(d) Citizenship;
(e) Marital status;
(f) Age;
(g) Sex;
(h) Home address; and
(i) Religion;
(2) Names, addresses, and telephone numbers
of referral agencies, including:
(a) Hospital
from which admitted;
(b) Personal
physician;
(c) Dentist;
(d) Parents' names or next of kin;
and
(e) Resident's
representative;
(3)
Documentation of the:
(a) Needs of the
resident;
(b) Establishment of an
appropriate initial and ongoing treatment plan; and
(c) Care and services provided;
(4) Authentication of hospital
diagnoses, based on a:
(a) Discharge
summary;
(b) Report from the
resident's attending physician; or
(c) Transfer form;
(5) Consent forms when required, such as:
(a) Administration of investigational
drugs;
(b) Burial arrangements made
in advance;
(c) Release of medical
record information; and
(d)
Handling of finances;
(6) Medical and social history of the
resident;
(7) Report of physical
examination;
(8) Diagnostic and
therapeutic orders;
(9)
Consultation reports;
(10)
Observations and progress notes;
(11) Reports of medication administration,
treatments, and clinical findings;
(12) Discharge summary including final
diagnosis and prognosis;
(13)
Assessments done by various disciplines; and
(14) Interdisciplinary care plan.
C. Staffing. An employee of the
nursing home shall be designated as the person responsible for the overall
supervision of the medical records service. There shall be sufficient support
staff to accomplish all medical records functions.
D. Consultation. If the medical records
supervisor is not a qualified medical record practitioner, the Department may
require that the supervisor receive consultation from a qualified
person.
E. Completion of Records
and Centralization of Reports.
(1) Current
medical records and those of discharged residents shall be completed
promptly.
(2) All clinical
information pertaining to a resident's stay shall be centralized in the
resident's medical record.
F. Retention and Preservation of Records.
(1) Medical records shall be retained for a
period of at least 5 years from the date of discharge or, in the case of a
minor, 3 years after the resident becomes of age or 5 years, whichever is
longer.
(2) The nursing home shall
maintain and dispose of a resident's medical records in accordance with
Health-General Article, Title 4, Subtitles 3 and 4, Annotated Code of
Maryland.
G. Current
Records - Location and Facilities. The nursing home shall maintain adequate
space and equipment, conveniently located, to provide for efficient processing,
reviewing, indexing, filing, and prompt retrieval of medical records.
H. Closed or Inactive Records. Closed or
inactive records shall be filed and stored in a safe place, free from fire
hazards, which provides for confidentiality and, when necessary,
retrieval.
I. Electronic Health
Records.
(1) A nursing home that uses
electronic health records exclusively or along with a paper-based medical
record shall comply with this chapter and all applicable State and federal
laws, including laws governing privacy and security of records.
(2) Staff and nursing home-approved
practitioners shall be trained in the use of electronic health
records.
(3) A nursing home that
uses electronic health records shall:
(a)
Ensure access to residents as specified in COMAR
10.07.09.08C(13) and
(14); and
(b) On request, provide the resident with
copies of the resident's medical records at a reasonable cost and in the
resident's preferred format.
(4) A nursing home shall provide full access
to electronic health records in accordance with all applicable laws and
regulations to:
(a) Representatives of the
Department as set forth in COMAR
10.07.02.07;
(b) An ombudsman as set forth in Human
Services Article, §10-905, Annotated Code
of Maryland; and
(c) Other legal
representatives as set forth in COMAR
10.07.09.08 and authorized by law
to obtain access.
(5) A
nursing home shall develop a system to ensure that nursing home staff have
access to residents' health records in the event of a failure of the nursing
home's electronic medical record system.