Nev. Admin. Code § 449.74441 - 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.

Notes

Nev. Admin. Code § 449.74441

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

NRS 449.0302