New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 370 - OVERSIGHT OF LICENSED HEALTHCARE FACILITIES AND COMMUNITY BASED WAIVER PROGRAMS
Part 15 - GENERAL REQUIREMENTS FOR BOARDING HOMES
Section 8.370.15.39 - RESIDENT RECORDS
Universal Citation: 8 NM Admin Code 8.370.15.39
Current through Register Vol. 35, No. 18, September 24, 2024
The licensee shall ensure that a separate, complete, and current record is maintained in the boarding home for each resident.
A. Each record must contain information including but not limited to the following:
(1) Name of resident, social security number,
phone number.
(2)
Birthdate.
(3) Gender.
(4) Date of admission.
(5) The source of referral and relevant
referral information.
(6) Names,
addresses, and telephone numbers of the authorized representative and emergency
contact.
(7) A signed and dated
copy of the admission agreement and resident's rights document.
(8) Name, address, and telephone number of
the resident's physician and dentist, and any other medical and mental health
providers.
(9) Medical assessments
and diagnosis, if applicable.
(10)
Record of any illness or injury requiring treatment by a physician or dentist
and for which the boarding home will provide assistance to the resident in
meeting their necessary medical and dental needs.
(11) An original or original copy of all
physician medication and treatment orders signed by the physician.
(12) Record of current medications, including
frequency and dosage; the name of the prescribing physician, and instructions,
if any, regarding control and custody of medications.
(13) A record of all contacts with medical
and other services.
(14) Needs and
services plan.
(15) Modified diet
requirements.
(16) Advanced
directives, or any preference for life saving measures if
appropriate.
(17) Signed consent
for the release of information, if information is released.
(18) Documentation of guardianship, agent or
other legal decision maker other than resident.
(19) A written account of all personal
possessions and funds deposited with the boarding home and accounting for all
funds spent and deposited subsequently by the resident.
B. Resident records should also include but are not limited to the following:
(1) Medical
and dental appointments.
(2)
Accidents or injuries.
(3) Any
problems or improvements observed in the resident.
(4) Any change in the resident's condition
which would indicate a need for higher level of care.
(5) Date, time, and services provided by a
visiting nurse service.
C. All information and records obtained from or regarding residents shall be confidential.
(1) The licensee shall be responsible for
safeguarding the confidentiality of record contents.
(2) Except as specified in (a) below, or as
otherwise authorized by law, the licensee and all employees shall not reveal or
make available confidential information.
(a)
All resident records shall be available to the licensing agency to inspect,
audit, and copy upon demand during normal business hours. Records may be
removed if necessary for copying.
(b) Removal of records shall be subject to
the following requirements:
(i) Licensing
representatives shall not remove current records for current residents unless
the same information is otherwise readily available in another document or
format.
(ii) Original resident
records or digital reproductions shall be retained for at least three years
following termination of service to the resident.
Disclaimer: These regulations may not be the most recent version. New Mexico 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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