Current through Register No. 52, December 26, 2024
(a) The licensee
shall maintain a legible, current, and accurate record for each client based on
services provided at the SUD-RTF.
(b) Client records shall contain the
following:
(1) A copy of the client's service
agreement and all documents required by He-P 826.16(c);
(2) Identification data, including:
a. Vital information including the client's
name, date of birth, and marital status;
b. Religious preference, if any;
and
c. Name, address and telephone
number of an emergency contact person;
(3) The name and telephone number of the
client's licensed practitioner(s);
(4) Contact information for the person
referring the client for services, as applicable;
(5) The name, address, and telephone number
of the behavioral health care provider, if applicable;
(6) The client'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
examination(s) in accordance with He-P 826.16(o) and (p);
(9) 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 SUD-RTF;
(10) Results of any laboratory tests, X-rays,
or consultations performed at the SUD-RTF;
(11) All evaluations and treatment plans,
including documentation that the client and the guardian, agent, or surrogate
decision-maker, if any, has participated in the development of the care and
treatment plans;
(12) All admission
and progress notes;
(13) If
services are provided at the SUD-RTF 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;
(14) 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;
(15) Documentation of any medical or
specialized care;
(16)
Documentation of unusual incidents;
(17) The consent for release of information
signed by the client, guardian, agent, or surrogate decision-maker, if
any;
(18) Discharge summary,
planning, and referrals;
(19)
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;
(20) The information required by He-P
826.16(k) as applicable;
(21)
Information data sheet, which contains the information required by He-P
826.16(s);
(22) Release of
information sheet;
(23)
Documentation of nurse delegation of medications as required by the nurse
practice act, as applicable; and
(24) 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 42 CFR Part 2,
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. For all SUD-RTF
facilities, this shall include compliance with 42 CFR Part 2.
(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 clients and personnel that include:
(1) Procedures for backing up files to
prevent loss of data;
(2)
Safeguards for maintaining the confidentiality of information pertaining to
clients and staff; and
(3) Systems
to prevent tampering with information pertaining to clients and
staff.
(g) Records shall
be retained for at least 7 years after discharge, except that when the client
is a minor, records shall, in addition, be retained 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
SUD-RTF ceases operation.
