New Hampshire Code of Administrative Rules
He - Department of Health and Human Services
Subtitle He-P - Former Division of Public Health Services
Section He-P 812.19 - Patient Records

Universal Citation: NH Admin Rules He-P 812.19

Current through Register No. 12, March 21, 2024

(a) A patient record shall be maintained for each patient accepted for treatment by the facility.

(b) The license shall maintain a legible, current, and accurate record for each patient based on the services provided at the ASC.

(c) At a minimum, patient records shall contain the following:

(1) Identification data including the patient's:
a. Name;

b. Home address;

c. Telephone number;

d. Name, address, and telephone number for an emergency contact;

e. Date of birth; and

f. Guardian, agent, or surrogate decision-maker, as applicable;

(2) A signed acknowledgment of receipt of the patients' bill of rights by the patient, guardian, agent, or surrogate decision-maker;

(3) Patient's health insurance information;

(4) Written or electronic record of a health examination by a licensed practitioner;

(5) Written, dated, and signed orders for medications, treatments, special diets, laboratory services, and referrals to other practitioners, as applicable;

(6) The consent for release of information signed by the patient, guardian, agent, or surrogate decision-maker, if any;

(7) The medication record;

(8) Documentation of any accident or injuries occurring while in the care of the facility;

(9) Documentation of all services provided including signed notes by:
a. Nursing personnel;

b. Physicians; and

c. Other health professionals authorized by ASC policy;

(10) Documentation of a patient's refusal of any care or services;

(11) Transfer or discharge documentation including planning, referrals, and notifications to the patient and guardian, agent, or surrogate decision-maker, if any, of involuntary room change, if applicable;

(12) Laboratory, x-rays, or results of other diagnostic tests; and

(13) The consent for treatment signed by the patient, guardian, agent or surrogate decision-maker, if any.

(d) Patient records shall be available to the professional staff and health care workers and any other person authorized by law or rule to review such records.

(e) Patient records shall be retained in the facility and stored in an area inaccessible to those who do not have authorized access to such records.

(f) The licensee's policy shall determine the method by which release of information from patient records shall occur.

(g) When not being used by authorized personnel, patient records shall be safeguarded against loss or unauthorized use by implementation of appropriate use, handling, and storage procedures.

(h) Patient records shall be retained 7 years after the discharge of a patient. In the case of minors, patient records shall be retained until at least one year after reaching age 18, but in no case shall they be retained for less than 7 years after discharge.

(i) The ASC shall arrange for the storage of and access to patient records for 7 years in the event the ASC ceases operation.

(j) The licensee shall arrange for storage of and access to patient records for 7 years in the event the clinic ceases operation.

(k) The facility shall notify the department where the storage required in (i) above is located.

(l) Referrals to other health care providers shall occur if medically indicated and the facility does not provide the services required.

(m) Electronic records shall be maintained according to current HIPAA regulations to ensure confidentiality and adequate security.

(n) If the facility uses an electronic record storage system, it shall provide computer access to all patient records for the purpose of verifying compliance with all provisions of RSA 151 and He-P 812 for the onsite inspection. Access shall include assistance navigating the database and printing portions of the record, if needed.

(o) Radiologic services shall only be provided when integral to procedures offered by the ASC.

(p) The ASC shall adopt and implement policy and procedures that provide safety for patient and personnel and are based on nationally recognized standards.

#9727-A, eff 6-18-10

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