Current through Register No. 40, October 3, 2024
(a) The licensee
shall maintain a legible, current, and accurate record for each client based on
services provided at the RTRF.
(b)
Client records shall contain the following:
(1) A copy of the client's service agreement
and all documents required by
He-P 807.16(c)
;
(2) Identification data, including:
a. Vital information including the client's
name;
b. Home address;
c. Home telephone number;
d. Name, address and telephone number for
emergency contact;
e. Date of
birth, and
f. Guardian, agent, or
surrogate decision-maker where applicable.
(3) The name and telephone number of the
client's licensed practitioner(s);
(4) The client's health insurance
information;
(5) 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;
(6) A record of the health
examination(s) in accordance with
He-P 807.16(m) and (o)
;
(7) 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 RTRF;
(8) Results of any laboratory tests, X-rays,
or consultations performed at the RTRF;
(9) All evaluations, assessments, and
treatment plans, including documentation that the client and the guardian or
agent, if any, has participated in the development of the care and treatment
plans;
(10) All admission and
progress notes;
(11) If services
are provided at the RTRF 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;
(12) 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;
(13) Documentation of any medical
or specialized care;
(14)
Documentation of reportable incidents;
(15) The consent for release of information
signed by the client, guardian, or agent, if any;
(16) Discharge summary, planning, and
referrals;
(17) 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;
(18) The
information required by
He-P 807.17(ai)
as applicable;
(19) Information data sheet, which contains
the information required by
He-P 807.16(s)
;
(20) Documentation of nurse delegation of
medications as required by the nurse practice act, as applicable; and
(21) 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 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.
(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 residents and personnel that, at a minimum,
include:
(1) Procedures for backing up files
to prevent loss of data;
(2)
Safeguards for maintaining the confidentiality of information pertaining to
residents and staff; and
(3)
Systems to prevent tampering with information pertaining to residents and
staff.
(g) Records shall
be retained for at least 7 years after discharge, except that when the client
is a minor, records shall be retained for 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 RTRF ceases operation.
