Find & Ask › North Dakota › this rule
NDAC 33-03-10.1-16 — Clinical Record Services
North DakotaregulationNorth Dakota Department of Health and Human Services
What this rule requires your agency to do
- 1Patient records of discharged patients must be preserved ten years from date of discharge (seven years for deceased patients); minors' records must be retained for the period of minority plus ten years (plus seven years for deceased minors) (subsection 9).(NDAC 33-03-10.1-16 — Clinical Record Services)
- 2The clinical record must contain the enumerated general categories of data, including identification/consent, physician contact information, the physician's signed order and approved plan of care, assessments, signed and dated notes, summary reports, diagnostic/therapeutic orders, treatment findings, transfer form, and discharge summary (subsection 1).(NDAC 33-03-10.1-16 — Clinical Record Services)
- 3All clinical information must be maintained in a centralized location by the parent or branch office (subsection 2).(NDAC 33-03-10.1-16 — Clinical Record Services)
- 4Clinical records must be safeguarded against loss or unauthorized use, with written policies governing use, removal, and release; release of non-statutorily-authorized information requires the patient's or legal representative's written consent (subsection 7).(NDAC 33-03-10.1-16 — Clinical Record Services)
- 5Entries for services rendered must be written within twenty-four hours and incorporated into the clinical record within the time frame specified by agency policy; entries must be made by the person providing services, state facts personally observed, and be signed and dated (subsections 4-5).(NDAC 33-03-10.1-16 — Clinical Record Services)
- 6The agency must maintain clinical records for each patient and provide relevant information from those records to personnel providing services in the patient's home (33-03-10.1-16 intro).(NDAC 33-03-10.1-16 — Clinical Record Services)
- 7Verbal orders from a physician must be signed and incorporated into the clinical record within a time frame consistent with agency policy (subsection 6).(NDAC 33-03-10.1-16 — Clinical Record Services)
Applies to: personal care
Requires the agency to maintain a clinical record for each patient with enumerated minimum contents, timely entries, confidentiality safeguards, and defined record-retention periods. Framework topic: Clinical Records & Documentation.
Regulatory information, not legal advice — always confirm against the cited official source. Verification reduces error; it does not certify compliance.