NAC449.379. Medical records.

     1. A hospital shall maintain a medical record for each person evaluated or treated in the hospital.

     2. The organization of the medical records service at the hospital must be appropriate to the scope and complexity of the services performed at the hospital. A hospital shall employ adequate personnel to ensure prompt completion, filing and retrieval of the medical records.

     3. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. A hospital shall use a system for author identification and record maintenance that ensures the integrity of the authentication of the record and protects the security of all entries to a medical record.

     4. Except as otherwise provided in this subsection, medical records must be retained in their original form or in a legally reproduced form for at least 5 years. The medical staff may identify specific items in a medical record that must be kept for at least 10 years. The hospital shall have a system for coding and indexing its medical records. The system must allow for the timely retrieval of information by diagnosis and procedure to support studies evaluating the medical care provided at the hospital.

     5. A hospital must have a procedure for ensuring the confidentiality of the medical records of its patients. Information from or copies of medical records may be released only to authorized persons, and the hospital shall ensure that unauthorized persons cannot gain access to or alter the medical records of its patients. Original medical records may be released by the hospital only in accordance with state or federal law, court orders or subpoenas.

     6. A medical record must include information:

     (a) Demonstrating the justification for the admission and continued hospitalization of a patient;

     (b) Supporting the diagnosis of the patient; and

     (c) Describing the progress of the patient and his or her response to the medications and services received during his or her hospitalization.

     7. All entries to a medical record must be legible and complete, and authenticated and dated promptly by the person who is responsible for ordering, providing or evaluating the service provided. In authenticating a medical record, the person shall include his or her name and discipline. Authentication may include the signature or written initials of the person or a computer entry by the person.

     8. All medical records must document the following information, as appropriate:

     (a) Evidence that a physical examination, including a history of the health of the patient, was performed on the patient not more than 7 days before or more than 48 hours after his or her admission into the hospital.

     (b) The diagnosis of the patient at the time of admission.

     (c) The results of all consultative evaluations of the patient and the appropriate findings by clinical and other staff involved in caring for the patient.

     (d) Documentation of any complications suffered by the patient, infections acquired by the patient while in the hospital and unfavorable reactions by the patient to drugs and anesthesia administered to the patient.

     (e) Properly executed informed consent for all procedures and treatments specified by the medical staff, or federal or state law, as requiring written patient consent.

     (f) All orders of practitioners, nursing notes, reports of treatment, records of medication, radiology and laboratory reports, vital signs and other information necessary to monitor the condition of the patient.

     (g) A discharge summary that includes a description of the outcome of the hospitalization, disposition of the case and the provisions for follow-up care that have been provided to the patient.

     (h) The final diagnosis of the patient.

     9. The medical record of a patient must be completed not later than 30 days after the date on which he or she is discharged.

     [Bd. of Health, Health Facilities Reg. Part III Ch. I § VI, eff. 10-9-69; A 8-26-74]—(NAC A by R050-99, 9-27-99)