Current through Register No. 40, October 3, 2024
(a) The licensee
shall maintain a legible, current, and accurate record for each client based on
services provided at the PRTP.
(b)
At a minimum, client records shall contain the following:
(1) A copy of the client's service agreement
and/or admission contract and all documents required by
He-P
830.16(d);
(2) Identification data, including:
a. Vital information including the client's
name, date of birth, and marital status;
b. Client's religious preference, if
known;
c. Client's veteran status,
if known;
d. Name, address, and
telephone number of an emergency contact person;
(3) The name and telephone number of the
client's licensed practitioner(s);
(4) The client's health insurance
information;
(5) 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 and DNR
or DNAR orders, if applicable;
(6)
A record of medical clearance in accordance with
He-P
830.16(n);
(7) 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 PRTP;
(8) Results of any laboratory tests, X-rays,
or consultations performed at the PRTP;
(9) All assessments and treatment plans,
including documentation that the client and the guardian or agent, if any, has
participated in the development of the treatment plans;
(10) All admission and progress notes,
including any use of restraints;
(11) If services are provided at the PRTP 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;
(12) 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;
(13) Documentation of any medical or
specialized care;
(14)
Documentation of unusual incidents;
(15) The consent for release of information
signed by the client, guardian, or agent, if any;
(16) Discharge planning and
referrals;
(17) Transfer or
discharge documentation, including notification to the client, guardian, or
agent, if any, of involuntary room change, transfer or discharge, if
applicable;
(18) The information
required by
He-P
830.17(ad) as applicable;
(19) The information data sheet required by
He-P 830.16(o) and
(p);
(20) Documentation of nurse delegation of
medications as required by the nurse practice act, as applicable;
(21) Documentation of a client's refusal of
any care or services; and
(22) The
licensee shall arrange for and document the immunization of all consenting
clients for pneumococcal disease, as applicable, and all consenting clients for
influenza in accordance with
RSA
151:9-b and report immunization data to the
department's immunization program.
(c) Client records and client 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 client's record shall occur. For all substance
abuse rehabilitation facilities, this shall include compliance with 42 CFR
Subpart 2C of the Centers for Medicare and Medicaid Services
regulations.
(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,
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 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 be
retained for 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 PRTP ceases operation.
