NAC449.15353. Records of clients.

     1. Each facility shall maintain an organized system for the records of clients.

     2. The records of a client must be available to professional members of the staff of the facility who are directly involved with the client.

     3. The records of clients must be available to representatives of the Division.

     4. The records of clients must include, without limitation:

     (a) Identification information;

     (b) Past medical and social history;

     (c) Copies of initial and periodic examinations;

     (d) Evaluations and progress notes; and

     (e) Assessments and goals of the plan of treatment of each client.

     5. The plan of treatment must state what service or person is responsible for providing treatment or services to the client.

     6. Entries must be made describing treatments and services rendered, medications administered, and any symptoms or other indications of illness or injury, including, without limitation, the date, time and action taken regarding each incident.

     7. Records must be adequately safeguarded against destruction, loss or unauthorized use.

     8. Records must be retained for at least 5 years after the discharge of a client from a facility.

     9. A discharge plan, as determined by a case management assessment of the client, must be documented for each client discharged from the facility.

     (Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000)