1. (a) The licensee shall maintain a legible, current, and accurate record for each patient based on services provided at the birthing center.

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

   1. (1) Identification data, including:

      1. a. Vital information including the patient’s name, home address, home phone number, date of birth, and marital status; and
      2. b. Name, address, and telephone number of an emergency contact person;
   2. (2) The name and telephone number of the patient’s licensed practitioner(s);
   3. (3) Patient’s health insurance information;
   4. (4) Copies of any executed legal orders and directives, such as guardianship orders issued under RSA 464-A, a durable power of attorney for healthcare executed in accordance with RSA 137-J, or a surrogate decision maker identified under RSA 137-J:35-37;
   5. (5) A record of the health exam as required by He-P 810.17(a)(5);

   6. (6) Written, dated, and signed orders for the following:

      1. a. All medications and treatments; and
      2. b. Laboratory services and consultations performed at the birthing center;
   7. (7) Results of any assessments, laboratory tests, x-rays, ultra sounds, or consultations performed at the birthing center;
   8. (8) All admission and progress notes;
   9. (9) Documentation of medical or specialized care;
   10. (10) Documentation of reportable incidents;
   11. (11) The consent for release of information signed by the patient, guardian, or agent, if any;
   12. (12) The medication record as required;
   13. (13) Documentation of any accident or injuries occurring while in the care of the birthing center and requiring medical attention by a practitioner;
   14. (14) Written and signed consent for the provision of care and services;
   15. (15) Written confirmation of the requirements in He-P 810.17(a)(1);
   16. (16) All written notes as required by He-P 810.17(r);
   17. (17) A discharge or transfer summary as required by He-P 810.17(v);
   18. (18) All progress notes including the signature of the person providing care; and
   19. (19) The emergency data sheet required by He-P 810.17(y).
3. (c) Patient records and patient information shall be kept confidential and only provided in accordance with law.
4. (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.
5. (e) When not being used by authorized personnel, patient records shall be safeguarded against loss or unauthorized use or access.
6. (f) Records shall be retained for 4 years after discharge, except that when the patient is a minor, records shall be retained until the person reaches the age of 19, but no less than 4 years after discharge.
7. (g) The licensee shall arrange for storage of, and access to, patient records as required by (f) above in the event the birthing center ceases operation.

Source. #8957, eff 7-27-07, EXPIRED: 7-27-15 New. #11039, INTERIM, 2-24-16, EXPIRES: 8-22-16; ss by #11161, eff 8-20-16; ss by #14074, eff 9-20-24, EXPIRES: 9-20-34