NAC449.74441. Maintenance.

     1. A facility for skilled nursing shall maintain medical records for each patient in the facility in accordance with accepted professional principles.

     2. A medical record must be:

     (a) Complete;

     (b) Accurate;

     (c) Organized; and

     (d) Readily accessible to those persons who are authorized to review the records.

     3. A medical record must include:

     (a) Sufficient information to identify the patient;

     (b) A record of the assessments of the patient conducted pursuant to NAC 449.74433 and 449.74435;

     (c) The patient’s plan of care and the services provided to the patient;

     (d) The results of any assessment of the patient conducted by a state agency before his or her admission to the facility; and

     (e) Periodic progress notes prepared by appropriate members of the staff.

     4. A facility for skilled nursing shall maintain the medical records of a patient:

     (a) For at least 5 years after the discharge of the patient, unless state law requires otherwise; and

     (b) For at least 3 years after the patient reaches 18 years of age if the patient is a minor.

     5. A facility for skilled nursing shall ensure that:

     (a) Information contained in a medical record is not lost, destroyed or used in an unauthorized manner.

     (b) No person willfully and knowingly falsifies or causes another person to falsify information contained in a medical record.

     6. Information contained in a medical record is confidential and must not be released without the written consent of the patient except:

     (a) As required by law;

     (b) Under a contract involving a third-party payor; or

     (c) As required upon the transfer of the patient to another medical facility.

     (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)