Current through Register No. 26, June 26, 2025
(a) The licensee shall maintain a legible,
current, and accurate record for each patient based on services provided at the
ESRDDC which includes, at a minimum:
(1) The
written confirmation required by
He-P
811.17(a)(2);
(2) The identification data required by
He-P
811.17(a)(3);
(3) Consent forms as required by
He-P
811.17(a)(4);
(4) Consent for release of information as
applicable required by
He-P
811.17(a)(5);
(5) The record of the medical history and
health examination required by
He-P
811.17(a)(6);
(6) All orders from a licensed practitioner,
including the date and signature of the licensed practitioner;
(7) Results of any laboratory
tests;
(8) All consultation
reports;
(9) All assessments for
the last 12 months;
(10) All care
plans for the last 12 months;
(11)
All written notes required by
He-P
811.17(b)(10);
(12) The medication record required by
He-P
811.18(w) and (z);
(13) Discharge or transfer documentation as
required by He-P
811.17(e);
(14) Documentation of nurse delegation of
medications as required by the nurse practice act, as applicable;
(15) The name and telephone number of the
patient's licensed practitioner;
(16) The patient's health insurance
information;
(17) Copies of any
executed legal orders and directives, such as guardianship orders issued under
RSA 464-A, a durable power of attorney for healthcare under RSA 137-J, or a
living will;
(18) Documentation of
reportable incidents; and
(19)
Documentation of any accident or injuries to the patient occurring while in the
care of the ESRDDC and requiring medical care by a
practitioner.
(b) Patient
records shall be:
(1) Safeguarded against
loss, damage, or unauthorized use; and
(2) Retained for 7 years from the date of the
patient's last contact with the licensee, unless, before that date, the patient
has requested that the file be transferred to another health care provider,
except that when the patient is a minor, records shall be retained for 7 years
or until the person reaches the age of 19, whichever is
longer.
(c) Patient
records and patient information shall be kept confidential and only provided in
compliance with all applicable federal and state statutes and administrative
rules.
(d) The licensee shall
arrange for storage of and access to patient records as required by (b)(2)
above in the event the ESRDDC ceases operation.
(e) The licensee shall develop and implement
a written policy and procedure document that specifies the method by which
release of information from a patient's record shall occur.
(f) Any licensee that maintains electronic
records shall develop written policies and procedures designed to protect the
privacy of patients 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
patients and staff; and
(3) Systems
to prevent tampering with information pertaining to patients and
staff.
(g) The ESRDDC
shall, upon request, provide a patient, guardian, personal representative, or
agent with a copy of the patient's record pursuant to the provisions of
RSA
151:21, X.
