1. (a) A patient record shall be maintained for each patient accepted for treatment by the facility.
2. (b) The licensee shall maintain a legible, current, and accurate record for each patient based on the services provided at the NEWCC.

3. (c) At a minimum patient records shall contain the following:

   1. (1) Identification data, including the patient’s:

      1. a. Name;
      2. b. Home address;
      3. c. Home telephone number;
      4. d. Name, address, and telephone number for an emergency contact;
      5. e. Date of birth; and
      6. f. Guardian, agent, or surrogate decision-maker when applicable;
   2. (2) A signed acknowledgment of receipt of the patient bill of rights and the facility’s complaint procedures, signed by the patient, guardian, agent, or surrogate decision-maker;
   3. (3) Patient's health insurance information;
   4. (4) A written or electronic record of a health assessment by a licensed practitioner or registered nurse;
   5. (5) Dated and signed orders for medications, treatments, special diets, laboratory service, and referrals to other practitioners, as applicable;
   6. (6) The consent for release of information signed by the patient, guardian, agent, or surrogate decision-maker, if any;
   7. (7) The medication record as required;
   8. (8) Documentation of any accident or injuries occurring while in the care of the facility and requiring medical attention by a practitioner;

   9. (9) Documentation of all services provided including signed progress notes by:

      1. a. Nursing personnel;
      2. b. Physicians; and
      3. c. Other health professionals authorized by facility policy;
   10. (10) Documentation of a patient’s refusal of any care or services;
   11. (11) Transfer or discharge documentation including planning, referrals, and notification to the patient and guardian, agent, or surrogate decision-maker, if any, of involuntary room change, if applicable;
   12. (12) Orders and results of any laboratory tests, x-rays, or other diagnostic tests; and
   13. (13) The name and telephone number of the patient’s licensed practitioner, if any.
4. (d) Patient records shall be available to the professional staff and health care workers and any other person authorized by law or rule to review such records.
5. (e) Patient records shall be retained in the facility and stored in an area inaccessible to those who do not have authorized access to such records.
6. (f) The licensee shall develop and implement a written policy and procedure that specifies the method by which release of information from a patient’s records shall occur.
7. (g) When not being used by authorized personnel, patient records shall be safeguarded against loss or unauthorized use by implementation of use, handling, and storage procedures.
8. (h) Patient records shall be retained 7 years after discharge of a patient. In the case of minors, patient records shall be retained until the patient reaches the age of 18, but in no case shall they be retained for less than 7 years after discharge.
9. (i) The licensee shall arrange for storage of and access to patient records for 7 years in the event the clinic ceases operation.
10. (j) The facility shall notify the department where the storage required in He-P 806.18(i) is located.
11. (k) Referrals to other health care providers shall occur if medically indicated and if the facility does not provide the services required.
12. (l) Electronic records shall be maintained according to current HIPAA regulations to ensure confidentiality and adequate security.
13. (m) 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 806 for the onsite inspection. Access shall include assistance navigating the database and printing portions of the record, if needed.

Source. #9655, eff 2-13-10, EXPIRED: 2-13-18 New. #12674, INTERIM, eff 11-19-18, EXPIRED: 5-20-19 New. #12795, eff 5-30-19; ss by #13987, eff 5-30-24 (formerly He-P 806.17)