Current through Register No. 40, October 3, 2024
(a) The licensee
shall maintain a legible, current, and accurate record for each resident based
on services provided at the ICF/IID.
(b) At a minimum, resident records shall
contain the following:
(1) A copy of the
resident's admission agreement and all documents required by
He-P
815.15(f);
(2) Identification data, including:
a. Vital information including the resident's
name, date of birth, and parent or guardian contact information;
b. Resident or resident's family's religious
preference, if known;
c. If an
adult, the resident's veteran status, if known, and marital status;
and
d. Name, address, and telephone
number of an emergency contact person;
(3) The name and telephone number of the
resident's licensed practitioner(s);
(4) Resident's health insurance
information;
(5) Copies of any
executed legal orders and directives, such as guardianship orders issued under
RSA 464-A or RSA 463, a durable power of attorney for healthcare, or a living
will;
(6) A record of the health
examination(s) in accordance with
He-P
815.15(k);
(7) Written, dated, and signed orders for the
following:
a. All medications, treatments, and
special diets; and
b. Laboratory
services and consultations;
(8) Results of any laboratory tests, or
consultations;
(9) All assessments
and care plans, and documentation that the resident and the guardian or agent,
if any, have been given the opportunity or has participated in the development
of the care plan;
(10)
Documentation of informed consent;
(11) All admission and progress
notes;
(12) Documentation of any
alteration in the resident'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 unusual incidents;
(15) The consent for release of information
signed by the resident, guardian, or agent, if any;
(16) Discharge planning and referrals as
applicable;
(17) Transfer or
discharge documentation, including notification to the resident, guardian, or
agent, if any, of transfer or discharge;
(18) Room change documentation, including
notification to the resident, guardian, or agent, if any, and if
applicable;
(19) The medication
record as required by
He-P
815.16(y) and (ac);
(20) Documentation of a resident's refusal of
any care or services; and
(21) Code
status.
(c) Resident
records and resident information shall be kept confidential and only provided
in accordance with 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 resident's
record shall occur.
(e) Resident
records shall be available to health care workers and any other person
authorized by law or rule to review such records.
(f) When not being used by authorized
personnel, resident records shall be safeguarded against loss or unauthorized
use or access.
(g) Records shall be
retained for 7 years after discharge, except for records of Medicaid residents,
which shall be retained for 6 years from the date of service or until the
resolution of any legal action(s) commenced during the 6-year period, whichever
is longer.
(h) The licensee shall
arrange for storage of, and access to, resident records as required by (g)
above in the event the ICF/IID ceases operation.
