NAC449.797. Contents of clinical records.

Clinical records must contain:

     1. The name, address and telephone number of the person who will be notified in an emergency involving the patient.

     2. Information as to whether home health services are after hospitalization in a hospital, skilled nursing facility or other health service facility and, if so, the dates of admission and discharge from these facilities.

     3. A clinical summary from the hospital, skilled nursing facility or other health service facility from which the patient is transferred to the home health agency.

     4. A plan for patient care which includes:

     (a) Objectives and approaches for providing services.

     (b) Diagnoses of all medical conditions relevant to a plan of treatment.

     (c) Physical traits pertinent to the plan for care.

     (d) Nursing services required and the level of care and frequency of visits, special care which is required, such as dressing and catheter changes, and specific observations to be brought to the physician’s attention.

     (e) Requirements of therapy, such as physical, speech, occupational or inhalation therapy with specific instructions for each.

     (f) Requirements of activity, such as the degree allowed and any assistance required.

     (g) Medical appliances needed, such as crutches, walkers, braces or equipment for respiratory care.

     (h) Nutritional needs.

     (i) Medical supplies needed, such as dressings or irrigation sets.

     (j) The degree of participation of the family in the care.

     5. A copy of:

     (a) The patient’s durable power of attorney for health care, if the patient has executed such a power of attorney pursuant to NRS 449.800 to 449.860, inclusive; and

     (b) A declaration governing the withholding or withdrawal of life-sustaining treatment, if the patient has executed such a declaration pursuant to NRS 449.600.

     6. Nurses’ notes that follow a good medical format, including pertinent observations regarding a patient’s physical and mental status, procedures done, examinations, dietary status and recommendations.

     7. Therapists’ notes, if applicable, stating the rehabilitative procedures, progress and the types, duration and frequency of the modalities rendered.

     8. A written evaluation for services made at the time the patient is admitted for care. Regular written reevaluations for services and assessments of patients made on a continuing basis.

     9. A report given to the attending physician, written or by phone, whenever unusual findings occur. A written progress note must be submitted to the physician at least every 62 days.

     10. A record of the termination of services, including the date and reason for termination and the time when the physician was notified of the termination.

     [Bd. of Health, Home Health Agencies Part II Chap. III § H subsec. 4, eff. 1-10-74]—(NAC A 11-13-96)