Nev. Admin. Code § 449.725 - Records
1. A facility must maintain an organized
system for keeping residents' records. A resident's records must be available
to professionals and other members of the staff who are directly involved with
the resident. The records must be available to representatives of the
Division.
2. The record for each
resident must include the following:
(a)
Information, relating to the resident's identification.
(b) Admission data, including past medical
and social history.
(c) Copies of
initial and periodic examinations, evaluations and progress notes.
(d) Assessments and goals of each plan of
care and modifications to the plan.
(e) Discharge summaries.
(f) An overall plan of care describing the
goals to be accomplished through individually designed activities, therapies
and treatments.
(g) The plan of
care must indicate which professional service or person is responsible for the
care or service.
(h) Entries
describing treatments and services rendered.
(i) Medications administered.
(j) All symptoms and other indications of
illness or injury, including the date, time and action taken regarding each
such incident.
3.
Records must be adequately safeguarded against destruction, loss or
unauthorized use.
4. Records must
be retained for a minimum of 3 years following the discharge of a
resident.
Notes
NRS 449.0302
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No prior version found.