Current through September 16, 2024
1. Each facility
shall establish a system for preparing and maintaining a clinical record for
each patient of the facility. The system must be developed to ensure that the
care provided to each patient of the facility is:
(a) Completely and accurately
documented;
(b) Readily available
for retrieval by the facility; and
(c) Systematically organized to facilitate
the compilation and retrieval of information.
2. If the facility maintains any clinical
record on microfilm, optical disc or by any other electronic means, the
facility shall ensure that the clinical record is available for review by the
Bureau within 48 hours after the facility receives a request for the clinical
record from the Bureau.
3. All
information concerning the medical history or care provided to or treatment
received by a patient at the facility must be:
(a) Maintained in the clinical record of the
patient; and
(b) Protected by the
facility against theft, loss or damage.
4. Each facility shall establish an area in
which to store the clinical records of the facility. The area must be separate
from any area of the facility that is used to provide treatment for patients of
the facility and must have adequate space for reviewing, dictating, sorting or
recording the information included in the clinical records. If a facility uses
an optical disc, microfilm or any other electronic means to create or maintain
a clinical record, the area used to store the clinical record must have
adequate space for transcribing the information created or maintained on the
optical disc, microfilm or by any other electronic means. If the facility
determines that the clinical record of a patient of the facility is active, the
facility shall store the active clinical record at the site of the
facility.
5. Each facility shall
ensure that:
(a) The clinical record of a
patient of the facility remains confidential and is retained in accordance with
the provisions of
NRS
629.051; and
(b) Each entry or other information that is
placed in the clinical record regarding the delivery of care to the patient is
not altered without evidence and explanation of that alteration. A signature
stamp must not be used to authenticate an entry in the clinical record of a
patient of the facility.
6. If a facility determines that a clinical
record is inactive, the facility shall store that clinical record. The facility
may store the record on microfilm, optical disc or by any other electronic
means and may store the clinical record at a location other than at the site of
the facility if the facility ensures that:
(a) The clinical record remains secure from
unauthorized access at that location; and
(b) The record is readily retrievable for
review by the Division.
7. Each clinical record must include:
(a) Information concerning the identity of
the patient for whom the clinical record is prepared;
(b) Each written notice provided to the
patient at the facility and each written consent obtained from the patient at
the facility;
(c) Each order
prepared by a physician at the facility concerning the patient;
(d) Each progress note prepared by the
facility concerning the patient;
(e) A list that specifies all problems
incurred concerning the treatment and care of the patient;
(f) The physical and medical history of the
patient;
(g) Each assessment
concerning the patient prepared by a registered nurse, social worker or
licensed dietitian employed by the facility;
(h) The record of each medication
administered by the facility to the patient:
(1) During treatment at the facility;
or
(2) For use at his or her
residence;
(i) The
record of each transfusion received by the patient at the facility;
(j) Each laboratory report prepared or
received by the facility concerning the patient;
(k) Each diagnostic study concerning the
patient that is ordered by the attending nephrologist;
(l) Each appropriate record of
hospitalization;
(m) Each record of
consultation with the patient that is requested by the attending
nephrologist;
(n) If practicable,
the record of creation and revision of access for each dialysis treatment
provided to the patient;
(o) Each
plan prepared by the facility concerning the care of the patient, including the
plan developed for the patient pursuant to the provisions of NAC 449.541 and
all amendments to that plan;
(p)
Evidence indicating that the facility has complied with the provisions of NAC
449.501 to 449.5795, inclusive, concerning the furnishing of educational
materials to the patient;
(q) Each
record of the daily treatment received by the patient at the facility;
and
(r) A discharge summary, if the
patient is discharged from the facility.
8. As used in this section, "progress note"
means a note or other written statement that:
(a) Is signed and dated by a member of the
staff of a facility; and
(b)
Summarizes the facts concerning the care provided to a patient of the facility
and the response of the patient to that care for the period specified in the
note or other written statement.
Added to NAC by Bd. of
Health by R130-99, eff. 8-1-2001; A by R090-12,
12-20-2012
NRS
449.0302
