12 Va. Admin. Code § 35-46-660 - Maintenance of residents' records
A. A separate written or automated case
record shall be maintained for each resident. In addition, all correspondence
and documents received by the facility relating to the care of that resident
shall be maintained as part of the case record. A separate health record may be
kept on each resident.
B. Each
record shall be kept up to date and in a uniform manner.
C. The provider shall develop and implement
written policies and procedures for management of all records, written and
automated, that shall describe confidentiality, accessibility, security, and
retention of records pertaining to residents, including:
1. Access, duplication, dissemination, and
acquiring of information only to persons legally authorized according to
federal and state laws;
2.
Facilities using automated records shall address procedures that include:
a. How records are protected from
unauthorized access;
b. How records
are protected from unauthorized Internet access;
c. How records are protected from
loss;
d. How records are protected
from unauthorized alteration; and
e. How records are backed up;
3. Security measures to protect
records from loss, unauthorized alteration, inadvertent or unauthorized access,
and disclosure of information and during transportation of records between
service sites;
4. Designation of
person responsible for records management ; and
5. Disposition of records in the event the
facility ceases to operate.
D. The policy shall specify what information
is available to the resident .
E.
Active and closed records shall be kept in areas that are accessible to
authorized staff and protected from unauthorized access, fire, and flood.
1. When not in use written records shall be
stored in a metal file cabinet or other metal compartment.
2. Facility staff shall assure the
confidentiality of the residents' records by placing them in a locked cabinet
or drawer or in a locked room when the staff member is not present.
F. Each resident 's written record
shall be stored separately subsequent to the resident's discharge according to
applicable statutes and regulations.
G. Written and automated records shall be
retained in their entirety for a minimum of three years after the date of
discharge unless otherwise specified by state or federal
requirements.
H. The face sheet
shall be retained permanently unless otherwise specified by state or federal
requirements.
I. Entries in a
resident 's record shall be current, dated, and authenticated by the person
making the entry. Errors shall be corrected by striking through and initialing.
If records are electronic, the provider shall develop and implement a policy
and procedure to identify how corrections to the record will be made.
Notes
Statutory Authority
§§ 37.2-408 and 37.2-203 of the Code of Virginia.
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