New Hampshire Code of Administrative Rules
He - Department of Health and Human Services
Subtitle He-P - Former Division of Public Health Services
Chapter He-P 800 - RESIDENTIAL CARE AND HEALTH FACILITY RULES
Part He-P 827 - FREESTANDING MEGAVOLTAGE RADIATION THERAPY FACILITY
Section He-P 827.19 - Patient Records

Universal Citation: NH Admin Rules He-P 827.19

Current through Register No. 40, October 3, 2024

(a) The licensee shall maintain a legible, current, and accurate record for each patient receiving the services provided at the FMRTF.

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

(1) Identification data, including:
a. The patient's name, date of birth, and marital status;

b. Home address and telephone number;

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

d. Patient's veteran status, if known; and

e. Guardian or agent, if applicable;

(2) The name and telephone number of the patient's licensed practitioner(s);

(3) A signed acknowledgment of receipt of patient bill of rights by the patient, guardian, or agent;

(4) If services are provided at the FMRTF by individuals not employed by the licensee, documentation that includes the name of the agency or individual providing the services, the date services were provided, a brief summary of the services provided, and the business address and telephone number;

(5) Patient's health insurance information;

(6) A written or electronic record of a health examination by a licensed practitioner;

(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) Written, dated, and signed orders for the all medications, treatments, and therapeutic diets ordered at the FMRTF;

(9) Copies of the patient's consent for treatment and DNR;

(10) Results of any laboratory tests, X-rays, or consultations performed at FMRTF;

(11) All assessments and care plans, and documentation that the patient and the guardian or agent, if any, has participated in the development of the care plan;

(12) The consent for release of information signed by the patient, guardian, or agent, if any;

(13) All consult and progress notes;

(14) Documentation of medical, nursing, or other specialized care, as applicable;

(15) Documentation of reportable incidents;

(16) The consent for release of information signed by the patient, guardian, or agent, if any;

(17) Discharge planning and referrals;

(18) The medication record as required by He-P 827.17(u);

(19) Documentation of any accident or injuries occurring while in the care of the facility and requiring medical attention by a practitioner; and

(20) Documentation of a patient's refusal of any care or services.

(c) Patient records and information shall be kept confidential and only provided in accordance with all applicable federal and state 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) A licensee shall, upon request, provide a patient or the patient's guardian or agent, if any, with a copy of his or her patient record pursuant to the provisions of RSA 151:21.

(g) All personnel records required for licensing shall be legible, current, accurate, and available to the department during an inspection or investigation conducted in accordance with RSA 151:6 and RSA 151:6-a.

(h) 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.

(i) Patient records shall be retained 7 years after discharge of a patient, and 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.

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

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

(l) 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 827 for the onsite inspection. Access shall include assistance navigating the database and printing portions of the record, if needed.

Disclaimer: These regulations may not be the most recent version. New Hampshire may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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