1. (a) Retention requirements for active clinical records.

   1. (1) The maintenance schedule for records on resident charts are as follows:

      1. (A) Admission and discharge records — Permanent;
      2. (B) Miscellaneous admission records — Permanent:

2. (i) Admission nurse’s notes;

   1. (ii) Admission height and weight;

      1. (iii) Advance directives;

         1. (iv) Informed restraint consent;
         2. (v) Patient rights; and
         3. (vi) Authorization for treatment;
      2. (C) History and physical — Most recent;
      3. (D) Rehabilitation Potential Evaluation — Most recent;
      4. (E) Physician's orders — Six (6) months;
      5. (F) Physician's progress notes — Six (6) months;
      6. (G) Resident body weight — Six (6) months;
      7. (H) Transfer forms — Twelve (12) months or most recent if older than twelve (12) months;
      8. (I) Laboratory and X-ray reports — Six (6) months or twelve (12) months if ordered less often than monthly;
      9. (J) Nurse's notes/nursing flow sheets (ADL, restraints, clinitest: results, intake, and output, etc.) — Three (3) months;
      10. (K) Medication and treatment records — Three (3) months;
      11. (L) Personal effects inventory — Most recent;
      12. (M) Hospital discharge summary (including history and physical) — Current twelve (12) months;
      13. (N) TB surveillance record — Permanent;
      14. (O) Classification status — Current; and

      15. (P) Consultant reports — Initial and most recent:

          1. (i) Physicians;
          2. (ii) Occupational therapist;
          3. (iii) Speech therapist;
          4. (iv) Physical therapist;
          5. (v) Social worker;
          6. (vi) Psychologist; and
          7. (vii) Others.

   2. (2) The maintenance schedule for active records in the nurse's station (other than those required to be maintained on the chart) are as follows:

      1. (A) Assessments and reassessments — Most recent twelve (12) months;
      2. (B) Plan of care, summary of quarterly progress notes, change of condition — Twelve (12) months;
      3. (C) Pharmacy reviews — Six (6) months;
      4. (D) PASRR Level I — Permanent; and
      5. (E) PASRR Level II — Most recent.

   3. (3) Those portions of the active records not kept on the chart or at the nurse's station must be:

      1. (A) Maintained in the facility; and
      2. (B) Retrievable within fifteen (15) minutes upon request.

3. (b) Requirements for retention and preservation of inactive/closed records.

   1. (1) Resident records will be retained in the facility for a minimum of five (5) years following discharge or death of the resident.
   2. (2) Resident records for minors will be kept for at least three (3) years after they reach legal age of eighteen (18) years of age.
   3. (3) The resident records will be kept on the premises at all times and will only be removed by subpoena.
   4. (4) In the case of change of ownership, the resident records will remain with the facility.
   5. (5) In case of closure, the records will be stored within the State of Arkansas for the retention period.
   6. (6) After the retention period is met, the records may be destroyed either by burning or shredding.
   7. (7) Records will be protected against loss, destruction or unauthorized use.

Codification Notes: “TB” means tuberculosis.