N.M. Admin. Code § 8.370.16.31 - MEDICAL RECORDS - GENERAL
A. Availability of records: Medical records
of current residents shall be stored in the facility and shall be easily
accessible, at all times, to persons authorized by the resident to obtain the
release of the medical records.
B.
Organization: The facility shall maintain a systematically organized records
system appropriate to the nature and size of the facility for the collection
and release of resident information.
C. Unit record: A unit record shall be
maintained for each resident and day care client.
D. Indexes: A master resident index shall be
maintained.
E. Maintenance: The
facility shall safeguard medical records against loss, destruction, or
unauthorized use, and shall provide adequate space and equipment to efficiently
review, index, file and promptly retrieve the medical records.
F. Retention and destruction:
(1) The medical record shall be completed and
stored within 60 days following a resident's discharge or death.
(2) An original medical record and legible
copy or copies of court orders or other documents, if any, authorizing another
person to speak or act on behalf of this resident shall be retained for a
period of at least 10 years following a resident's discharge or death. All
other records required by these regulations shall be retained for the period
for which the facility is under review.
(3) Medical records no longer required to be
retained under this section may be destroyed, provided:
(a) the confidentiality of the information is
maintained; and
(b) the facility
permanently retains at least identification of the resident, final diagnosis,
physician, and dates of admission and discharge.
(4) A facility shall arrange for the storage
and safekeeping of records for the periods and under the conditions required by
this paragraph in the event the facility closes.
(5) If the ownership of a facility changes,
the medical records and indexes shall remain with the facility.
G. Records documentation:
(1) All entries in medical records shall be
legible, permanently recorded, dated, and authenticated with the name and title
of the person making the entry.
(2)
Symbols and abbreviations may be used in medical records if approved by a
written facility policy which defines the symbols and abbreviations and which
controls their use.
Notes
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