Current through Register No. 40, October 3, 2024
(a) The licensee
shall maintain a legible, current, and accurate record for each patient based
on services provided at the HH.
(b)
At a minimum, patient records shall contain the following:
(1) A copy of the patient's service agreement
and/or admission contract and all documents required by
He-P
824.16(c)(1);
(2) Notwithstanding (1) above, financial
records may be kept in a separate file;
(3) Identification data, including:
a. Vital information including the patient's
name, date of birth, and marital status;
b. Patient's religious preference, if
known;
c. Patient's veteran status,
if known; and
d. Name, address and
telephone number of an emergency contact person;
(4) The name and telephone number of the
patient's licensed practitioner(s);
(5) For individuals contracted by the HH or
the patient to provide services at the HH, their name, employer, business
address and telephone number;
(6)
Patient's health insurance information;
(7) 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;
(8) A record of the health assessment in
accordance with He-P
824.16(e)(1);
(9) Written, dated, and signed orders for the
following:
a. All medications, treatments and
special diets; and
b. Laboratory
services and consultations performed at the HH;
(10) Results of any laboratory tests, X-rays,
or consultations performed at the HH;
(11) All admission and progress
notes;
(12) For services that are
provided at the HH by individuals who are not employed by the licensee,
documentation shall include 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;
(13) Documentation of medical or specialized
care;
(14) Documentation of
reportable incidents;
(15) The
consent for release of information signed by the patient, guardian or agent, if
any;
(16) The medication record as
required;
(17) Documentation of any
accident or injuries occurring while in the care of the facility and requiring
medical attention by a practitioner;
(18) Documentation of a patient's refusal of
any care or services; and
(19) The
licensee shall arrange for and document the immunization of all consenting
patients for pneumococcal disease, as applicable, and all consenting patients
for influenza in accordance with
RSA
151:9-b and report immunization data to the
department's immunization program.
(c) Patient records and patient 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 patient's record shall occur.
(e) When not being used by authorized
personnel, patient records shall be safeguarded against loss or unauthorized
use or access.
(f) Records shall be
retained for 4 years after discharge, except that when the patient is a minor,
records shall be retained until the person reaches the age of 19, but no less
than 4 years after discharge.
(g)
The licensee shall arrange for storage of, and access to, patient records as
required by (g) above in the event the HH ceases operation.
