Kan. Admin. Regs. § 26-42-105 - Resident records

(a) The administrator or operator of each home plus shall ensure the maintenance of a record for each resident in accordance with accepted professional standards and practices.

(1) Designated staff shall maintain the record of each discharged resident who is 18 years of age or older for at least five years after the discharge of the resident.

(2) Designated staff shall maintain the record of each discharged resident who is less than 18 years of age for at least five years after the resident reaches 18 years of age or at least five years after the date of discharge, whichever time period is longer.

(b) Each administrator or operator shall ensure that all information in each resident's record, regardless of the form or storage method for the record, is kept confidential, unless release is required by any of the following:

(1) Transfer of the resident to another health care facility;

(2) law;

(3) third-party payment contract; or

(4) the resident or legal representative of the resident.

(c) Each administrator or operator shall ensure the safeguarding of resident records against the following:

(1) Loss;

(2) destruction;

(3) fire;

(4) theft; and

(5) unauthorized use.

(d) Each administrator or operator shall ensure the accuracy and confidentiality of all resident information transmitted by means of a facsimile machine.

(e) If electronic medical records are used, each administrator or operator shall ensure the development of policies addressing the following requirements:

(1) Protection of electronic medical records, including entries by only authorized users;

(2) safeguarding of electronic medical records against unauthorized alteration, loss, destruction, and use;

(3) prevention of the unauthorized use of electronic signatures;

(4) confidentiality of electronic medical records; and

(5) preservation of electronic medical records.

(f) Each resident record shall contain at least the following:

(1) The resident's name;

(2) the dates of admission and discharge;

(3) the admission agreement and any amendments;

(4) the functional capacity screenings;

(5) the health care service plan, if applicable;

(6) the negotiated service agreement and any revisions;

(7) the name, address, and telephone number of the physician and the dentist to be notified in an emergency;

(8) the name, address, and telephone number of the legal representative or the individual of the resident's choice to be notified in the event of a significant change in condition;

(9) the name, address, and telephone number of the case manager, if applicable;

(10) records of medications, biologicals, and treatments administered and each medical care provider's order if the facility is managing the resident's medications and medical treatments; and

(11) documentation of all incidents, symptoms, and other indications of illness or injury including the date, time of occurrence, action taken, and results of the action.

Notes

Kan. Admin. Regs. § 26-42-105

Authorized by and implementing K.S.A. 39-932; effective May 29, 2009.