175 NAC 14-006.10 — Standards of Operation, Care, and Treatment: Record Keeping Requirements

What this rule requires your agency to do

• 1Agencies with branch offices/subunits must maintain specified patient information in the parent agency; and upon transfer to another facility/agency, must promptly forward necessary information with patient/designee consent (14-006.10I, 14-006.10J).(175 NAC 14-006.10 — Standards of Operation, Care, and Treatment: Record Keeping Requirements)
• 2Clinical records must be retained in retrievable form for at least five years after the last discharge (or, for a minor, five years after reaching majority), disposed of by shredding/mutilation/burning with permanent documentation of destruction, and safeguarded against loss, destruction, and unauthorized use (14-006.10H, 14-006.10H1, 14-006.10H2).(175 NAC 14-006.10 — Standards of Operation, Care, and Treatment: Record Keeping Requirements)
• 3The agency must obtain an informed consent form specifying the type of care and services for every individual, from the individual or designee (14-006.10H3).(175 NAC 14-006.10 — Standards of Operation, Care, and Treatment: Record Keeping Requirements)
• 4Entries must be made by the person providing services, contain personally observed facts, and be signed with full name (initials only if identified in the record); all physician verbal orders must be signed and incorporated into the record within 30 days (14-006.10E, 14-006.10F).(175 NAC 14-006.10 — Standards of Operation, Care, and Treatment: Record Keeping Requirements)
• 5Clinical records must be secured in locked storage under written policies governing use, removal, and release; release of information not authorized by law requires the patient's or legal designee's written consent (14-006.10G).(175 NAC 14-006.10 — Standards of Operation, Care, and Treatment: Record Keeping Requirements)
• 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; each record must contain sufficient information to identify the patient, justify the diagnosis/treatment, and document results, including the enumerated data categories (14-006.10, 14-006.10A).(175 NAC 14-006.10 — Standards of Operation, Care, and Treatment: Record Keeping Requirements)
• 7The agency must have and maintain required agency-level records (service policies, admission/discharge policies, grievance procedures, orientation/in-service training records, outside-resource contracts, personnel records, and QA records) and make records required by 175 NAC 14 available for inspection and copying by authorized Department representatives (14-006.10K, 14-006.10L).(175 NAC 14-006.10 — Standards of Operation, Care, and Treatment: Record Keeping Requirements)
• 8All clinical information must be centralized in the patient's clinical record, kept in ink, typed, or on electronic data systems; entries must be written within 24 hours and incorporated into the record within seven working days (14-006.10B, 14-006.10C, 14-006.10D).(175 NAC 14-006.10 — Standards of Operation, Care, and Treatment: Record Keeping Requirements)